Apply for Services - Child Autism

Mother/Guardian*

Father/Guardian*

Child's Name*

Child's Date of Birth*

Address*

Landline

Mobile

Email

1. Is your child currently attending nursery/school?*

Yes

No

2. Is your child currently on an ABA programme?*

Yes

No

3. Does your child have an additional medical condition?*

Yes

No

Please complete the following details as comprehensively as you can.

4. Please describe the nursery/school placement that your child currently attends

How long has your child attended the nursery/school?

How many hours does your child attend for?

Does your child receive additional support in the classroom, such as an LEA appointed assistant or an ABA tutor?

Have you had or do you have an annual review to attend, if so when?

5. Who is your current ABA Service Provider?

Please describe the programme that is currently/was previously in place, for example, types of skills taught, hours per week, how long the programme has been running for.

6. Please give details of your child’s medical condition e.g. diagnosis and treatment.

How did you find out about Child Autism UK's services?

Other (please specify)

Application for Services

Please complete the following details as comprehensively as you can.

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