Client Intake/Application

Client First Name *

Client Last Name *

E-Mail *

Client Birthday *

Guardian’s First Name *

Guardian’s Last Name *

Primary Guardian’s Email *

Primary Guardian’s Phone *

Address *

City *

State *

Zip *

Current Diagnosis * Autistic DisorderAspergers DisorderPervasive Developmental Disorder (PDD-NOS)OtherNot Yet Diagnosed

School Placement

Primary Spoken Language

Client Gender MaleFemale

Primary Guardian FatherMotherOther

Referred By: DoctorRelativeSchoolOther

Frequency of Current Treatments & Services

0 + 5 = ? Please prove that you are human by solving the equation *