Online Intake Form

Complete this easy ONLINE INTAKE FORM with general information about your service needs. This will create an intake account for you in our system.

Someone from our staff will email you within two business days to begin the intake process. If you do not see an email, please check your spam or junk folders.

Please enable JavaScript in your browser to complete this form.

Parent/Guardian Information:

Full Name: *

First

Last

Relationship To Child:

Contact Phone Number: *

Email: *

Child’s Information:

Child's Full Name: *

First

Last

Date of Birth: *

Gender:

• Female
• Male

Health Insurance

• Medical Assistance
• Private
• Other

Primary Language:

Medical and Developmental History:

Has your child been formally diagnosed with autism?

• Yes
• No

If yes, please specify the date of diagnosis and the diagnosing professional/organization.

Does your child have any other diagnoses (e.g., ADHD, sensory processing disorder)?

• Yes
• No

If yes, please list below

Behavioral Information:

Describe any behavioral challenges your child has experienced (e.g., tantrums, non-compliance, aggression)

How does your child typically communicate (e.g., verbal, non-verbal, use of assistive devices)?

Does your child have any specific sensory sensitivities or preferences?

Therapy and Educational Background:

Has your child received any therapy services before (e.g., Speech Therapy, Occupational Therapy)?

Please provide details.

What is your child’s current educational setting (e.g., mainstream school, special education, homeschooling)?

Family and Social Context:

Please describe your family structure (e.g., siblings, single parent).

How does your child interact with siblings and peers?

Are there any cultural or religious considerations that the therapy team should be aware of?

Goals and Expectations:

What are your immediate goals for your child in joining us at Sunrise Autism Center?

Are there specific skills or areas you hope your child will develop during their time at the center (e.g., social skills, independence, communication)?

Is there anything else about your child or family that you feel is important for us to know?

Submit