Diagnostic Testing Form
Child's Full Name
*
Child's Date of Birth
*
-
Month
-
Day
Year
Mother's Name
Father's Name
Primary Insurance Provider
*
Policyholder's Name
*
Policyholder's Date of Birth
*
-
Month
-
Day
Year
Policyholder's Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Primary Care Physician Name
*
First Name
Last Name
Primary Care Physician Phone
-
Area Code
Phone Number
Who referred your child to ABC for an assessment?
*
Is English the primary language in the home?
Yes
No
What are your current concerns about your child, or the reasons for the assessment?
*
Age problems were first noted.
*
Describe problems when first noted.
*
Did your child ever lose skills? If yes, describe skills lost and ages.
*
Has your child had a hearing test? If yes, what were the results?
*
Has your child been previously been tested or diagnosed with Autism? If so, when.
*
Please list any concerns about your child's learning, development, and behavior.
*
Please check any of the following conditions that your child has been diagnosed with:
*
Gastrointestinal (GI) problems
Epilepsy
Feeding issues
Disrupted sleep
Attention-deficit/hyperactivity disorder (ADHD)
Anxiety
Depression
Obsessive compulsive disorder (OCD)
Schizophrenia
Bipolar Disorder
None
Has your child been given any developmental, emotional, or behavioral diagnoses in the past? If so, please briefly describe these, including who diagnosed them and when.
*
Have you or anyone else had concerns about delays or problems with your child's development? If so, please briefly describe your concerns.
*
Has your child participated in an early intervention program (i.e. First Steps)?
*
Yes
No
If so, please describe.
If your child is in school, have his or her teachers expressed concerns about your child's social, emotional academic functioning? If so, please briefly describe these concerns.
*
Does your child have an IEP/special ed services? If so, please provide a copy by email, mail, or dropping it off at the center.
*
Yes
No
Please select one of the following:
*
I AM willing to follow a clinical recommendation of ABA therapy.
I AM NOT willing to follow a clinical recommendation of ABA therapy.
Security Question
*
Submit
Should be Empty: