Autism Tree Project · New Intake Form for Autism Tree Programs

Contact Information

Which of the following roles best describes you?

*

Name

*

First Name

Last Name

Name of Spouse/Partner

First Name

Last Name

Phone

*

Is this your mobile or home phone number?

*

Mobile

Home

Would you like to receive RSVP reminders for upcoming program events you are interested in?

*

Yes

No

How do you prefer to be reminded about upcoming events?

*

Phone

Email

Text

All of the above

Email

*

Verify Email

*

Would you like to join our monthly e-newsletter?

*

Our e-news contains all our latest news and upcoming events to keep you and your family connected

Yes

No

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Please complete additional information below.

Your answers will provide insight into how to best include and support you and your family in our community!

Name of Child with Autism

*

Child with Autism Date of Birth

*

(mm/dd/yyyy)

Please select the early intervention services your child is currently receiving.

Speech & Language Therapy

Occupational Therapy

Physical Therapy

ABA Therapy

Music Therapy

Animal Therapy

Does your child with autism have any siblings?

*

Yes

No

Name of Sibling 1

Sibling 1 Date of Birth

(mm/dd/yyyy)

Does Sibling 1 have Autism or any other kind of diagnoses?

Yes

No, they are neurotypical

Name of Sibling 2

Sibling 2 Date of Birth

(mm/dd/yyyy)

Does Sibling 2 have Autism or any other kind of diagnoses?

Yes

No, they are neurotypical

Name of Sibling 3

Sibling 3 Date of Birth

(mm/dd/yyyy)

Does Sibling 3 have Autism or any other kind of diagnoses?

Yes

No, they are neurotypical

Names & Ages of Additional Siblings

What are your Top 3 Areas of Concern for Your Child with Autism?

*

How did you learn about Autism Tree? (optional)

Additional Questions/Comments (optional)