Receiving IEP services?

If yes, please list all accommodations being received:

Mother

Father

Does your child have a history of seizures?

If yes, please describe frequency and type:

Is your child currently taking any medications?

If yes, please list medications, dosages, and purpose:

Does your child have any other diagnoses in addition to autism?

If yes, please specify:

Does your child use a hearing aid or speech assistant device?

Is your child potty trained?

Would you like help with potty training your child?

Do you have any additional information you would like to share?

Does your child have a history of elopement (running away)?

If yes, how frequently does this occur?

Does your child display aggressive behaviors?

If yes, please describe:

Does your child currently receive any of the following? (Check all that apply)

If yes, please provide details about the frequency and providers:

Would you like for your child to receive chiropractic care as part of their treatment plan?

Would you like a nutritionist to work with your child?

From time to time, ZAC ABA Therapy and Respite Care Autism Center may take photographs or videos of your child for educational, promotional, or documentation purposes. We request your consent for the use of such media in which your child may be featured.

I give consent for my child to be photographed and/or video recorded:

I give consent for my child’s photos/videos to be used for promotional materials or educational purposes:

By submitting this form, I acknowledge that all the information provided is accurate and complete to the best of my knowledge. I also understand and consent to the decisions I’ve made regarding my child’s participation in therapies and media usage.