Diagnostic Testing Form
Child's Full Name
Child's Date of Birth
Primary Insurance Provider
Policyholder's Date of Birth
Street Address Line 2
District of Columbia
Primary Care Physician Name
Primary Care Physician Phone
Who referred your child to ABC for an assessment?
Is English the primary language in the home?
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
Attention-deficit/hyperactivity disorder (ADHD)
Obsessive compulsive disorder (OCD)
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)?
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.
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.
Should be Empty: