Social Skills Registration

PARENT / GUARDIAN INFORMATION

Parent/Guardian First Name

Parent/Guardian Last Name

Phone

Alternate Phone

Town / City

How did you hear about us?

Best way to contact:

Phone Email No preference

CLIENT INFORMATION

Client First Name

Client Last Name

Client date of birth

Does the client have an official autism (ASD) diagnosis?

Yes No

Details:

Is the client currently receiving services through RCS?

Yes No

Is the client currently receiving ABA services from another provider (other than RCS)?

Yes No

Please select days your child is available for sessions (select all that apply):

Monday afternoon Tuesday afternoon Wednesday afternoon Thursday afternoon

INSURANCE INFORMATION

Insurance Provider

Secondary Insurance Provider (if applicable)

Please let us know about any specific questions you have about our program: