Open Enrollment Form

General Information

Child's Name: *

This is a required question

Child's Date of Birth *

This is a required question

Home Phone Number *

This is a required question

Home Address *

This is a required question

Mother's Name *

This is a required question

Mother's Cell Phone Number *

This is a required question

Mother's Buisness Phone Number

This is a required question

Mother's email address *

This is a required question

Father's Name *

This is a required question

Father's Cell Phone Number *

This is a required question

Father's Business Phone Number

This is a required question

Father's email address *

This is a required question

Day attending *

Monday (ages 12-14)
Tuesday (ages 6-8)
Wednesday (ages 9-11)
Thursday (ages 15+) Community outing group

This is a required question

Referred by

This is a required question

Siblings (Include name, age, learning &/or medical problems)

This is a required question

Who made the diagnosis?

This is a required question

When was the diagnosis made?

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Describe the concerns you have that prompted your referral for ASAP. *

e.g. behavioral problems, problem solving skills, personal/social skills, speech or language development.

This is a required question

Social and Behavioral Information

Is your child on any special diet? Does he/she take any medication or nutritional supplements?

If yes, please describe

This is a required question

Does your child have any allergies? *

If yes, please describe

This is a required question

Does your child have "outbursts" or "meltdowns" due to anger, frustrations, and/or sensory overload?

This is a required question

If yes, please describe what the behavior looks like.

e.g. Flops to the floor, hits, spits, screams, etc.

This is a required question

Describe your child's play/social skills. *

withdrawn, uninterested, interested but hesitant, interactive with peers, etc.

This is a required question

What does your child enjoy doing in his/her free time?

This is a required question

What are your child's special interests, likes and dislikes? What rewards or motivates your child? *

This is a required question

Is your child typically compliant with adult demands?

This is a required question

If no, what are some strategies you have used that gains compliance after a demand has been placed?

This is a required question

How does your child handle change in schedule/routine? *

Calmly. Ignores/copes with change with ease
Adapts quickly, but, with minor distress
Annoyed. Complains, but will ultimately persevere through change.
Shows considerable distress. Requires substantial preparation for change
Adapts to minor changes with preparation. But, may demonstrate negative behavior

This is a required question

How does your child transition between activities in a group? *

Independently follows classroom instructions
Gets distracted, may need an extra prompt
Often needs individualized instruction to transition

This is a required question

Educational History

Name of School *

This is a required question

Current Grade

This is a required question

Teacher's Name

This is a required question

Has your child received any of the following special services? *

This is a required question

If so, at what age did each service start and end? *

e.g. Speech age 2-4, ABA age 2-6, etc.

This is a required question

Any other pertinent information?

This is a required question

Mitchell's Place ASAP Enrollment Form

General Information

Social and Behavioral Information

Educational History