Pervasive developmental disorder nos and autism treatment services with Family First, Fairfield County, CT

Let's Get Started

APPLICATION

**Child's Information**
Child's Name: Birth Date: // Gender:
Address: City:
State: Zip: Phone #:
e-mail: Pediatrician:
Please list any major medical problems:
Does your child have a developmental diagnosis? If yes, what is diagnosis?
Age of child at initial diagnosis: years Who made the diagnosis?

**Family Information**
Mother's Name: Birth Date: //
Occupation: Schooling:
Father's Name: Birth Date: //
Occupation: Schooling:
Marital Status: If other, explain:
Other Caregiver's Name: Birth Date: //
Occupation: Schooling:
Names & Ages of siblings:
List the names of those living in the household other than the immediate family:
List the names of those living in the household other than the immediate family:

**Educational Information**
Is your child in a Birth to Three Program? School District Program?
Agency or School Name: District:
Address: City:
State: Zip:
Age when first enrolled in either of the above? years months
Number of hours your child spends in an early intervention program per week:
Is your child enrolled in a community preschool program?
If “yes”, what are the days and times?

Therapies/Interventions
Therapy/Intervention	Agency	Start Date	Frequency	Session Length
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Please total the number of hours per week of all therapies outside of school:

**Parent Involvement**
Are you familiar with DIR / Floortime Techniques?
Are you using these with your child?
If yes, please estimate the number of hours per week:

**Other Information**
Is there anything else you would like to tell us about your child?