1 Step Ahead Services Inc - Autism Consultant and Behavior Intervention in British Columbia

Services > Intake

Intake Application

Child's Name:		DOB (MM/DD/YY):
Parent's Name:
Current Diagnosis:		Age Diagnosed:
Address:		Phone:
		Email:
Date Funding Received (MM/DD/YY):	Invoice Direct

Does your child...
	Match objects or pictures?		Yes No
	Imitate actions of others?		Yes No
	Follow directions?		Yes No
	Use words to ask for things?		Yes No
	Play with toys?		Yes No
	Greet you when you arrive home?		Yes No
	Identify shapes, colors, numbers & letters?		Yes No

Autism Consultant and Behavior Intervention in British Columbia