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CHAC Final application

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CHAC Final application Powered By Docstoc
					                                                         Detroit
                                                         3901 Beaubien
                                                         Detroit, MI 48201
                                                         Novi
                                                         41935 12 Mile Rd.
                                                         Novi, MI 48377
                                                         (248) 305-6172
                                                         geri@pet.wayne.edu




                 Children’s Hospital of Michigan
                         Autism Center
                           Application




                                                         Diane Chugani PhD
Children’s Hospital of Michigan
                                                         Program Director
Autism Center Application                                Sara Chase
To enroll in our Behavioral Consultation and Treatment   Licensed Psychologist
Planning Service, complete and return the application    Geralyn DeBoard
and the non-refundable application fee.                  Administrative Director
                                                         Krista Kennedy M.S., LLP
                                                         Director of Behavior Services
        Information About Your Child                     Jill Matson MSN, RN, CPNP
        (Please type or print neatly)
                                                         Nurse Coordinator
Child’s Information:
Client Name:    ___________________________________________________

Date of Birth: ___/____/______ Height: ________ Weight: ________

Home Address: ______________________________________ City: ____________________________

State: _______________ Zip Code: __________ Home Phone #: (____)_____-_______

Parent Information:
Father’s Full Name: _________________________________________________Date of birth: __/__/__

Resides With Client: Y _________ N ________

Employer: ________________________________________ Employer Phone #: (____)_____-_______

Employer Address: ___________________________________________________________________

State: _______________ Zip Code: __________             Email:                     ____________

Mother’s Full Name: ___________________________________________Date of Birth: __/__/__

Resides With Client: Y __________ N ________

Employer: ________________________________________Employer Phone #: (____)_____-_______

Employer Address: ___________________________________________________________________

State: _______________ Zip Code: __________             Email:                           _____

Sibling Information:
1. Name: ____________________ Age: _____ Gender: ____ Resides With Client: Y_______ N______

2. Name: ____________________ Age: _____ Gender: ____ Resides With Client: Y_______ N______

3. Name: ____________________ Age: _____ Gender: ____ Resides With Client: Y_______ N______

Others living In the Home:
Name: ________________________________________ Relationship To Client: _________________

How Long Has This Person resided With the Client: ________________________________________

Name: _________________________________________ Relationship To Client: _________________

How Long Has This Person Resided With the Client: _________________________________________

How Did You Hear About CHACE? ______________________________________________________

Availability:

What days and times (days, nights, weekends) are you available for consultation?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Are you able to come to Novi for consultation?____________________


Current Treatment Team:
Primary Physician: ___________________________________________________________________
Address: ______________________________________ City: ________________________________
State: ___________________ Zip Code: _____________ Phone #: (____)_____-_______

Current Diagnosis: _____________________________ Diagnosed by: ___________________________
Date Determined: ______________________

Additional Diagnosis: ___________________________Diagnosed by: ___________________________
Date Determined: ______________________
Psychiatrist: _________________________________________________________________________
Address: _______________________________________ City: ________________________________
State: ____________________ Zip Code: ______________ Phone #: (____)_____-________

Speech Therapist (other than school): ______________________________________________________
Address: _______________________________________ City: ________________________________
State: ____________________ Zip Code: ______________ Phone #: (____)_____-________

Occupational Therapist (other than school): ________________________________________________
Address: _______________________________________ City: ________________________________
State: ___________________ Zip Code: ______________ Phone #: (____)_____-________

Physical Therapist (other than school): _____________________________________________________
Address: _______________________________________ City: ________________________________
State: ___________________ Zip Code: ______________ Phone #: (____)_____-________

Additional Physician/Therapist: __________________________________________________________
Address: _______________________________________ City: ________________________________
State: ___________________ Zip Code: ______________ Phone #: (____)_____-________

Past Treatment Services:
Type: __________________________________Therapist: _____________________________________
Hours per day ___________ Hours per week __________
Type: __________________________________Therapist: _____________________________________
Hours per day ____________ Hours per week ___________


Educational Information:
Current School: _______________________________________________________________________
Address: _________________________________________ City: ______________________________
State: __________________ Zip Code: _______________ Phone #: (____)_____-________

Teacher: ____________________________________________________________________________
Principal_____________________________________________________________________________

Class Placement: ________________________________________________________ Grade: _______

Current School Services:

1. Type: __________________________________Therapist: ___________________________________
Hours per day _______ Hours per week ________

2. Type: __________________________________Therapist: __________________________________
Hours per day _______ Hours per week ________

3. Type: __________________________________Therapist: __________________________________
Hours per day ________ Hours per week _________


Presenting Problem(s):
Academic:
__________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Social:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Daily Living:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________


Behavioral:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

What Are Your Short Term Goals for Treatment?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

                                                                                                 _______

What Are Your Long Term Goals for Treatment?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Every child communicates in a variety of ways. Please select the communication systems utilized by
your child; check all that apply:
______ Verbal communication                      ______ Brings the desired object to the caregiver
______ Crying/ whining                                           ______ Picture board/ book

______ Picture board/ book                                       ______ WOLF
______ Signs/ signals                                            ______ Other VOCA
______ Visual cues (looking at desired object)                   ______ Other

______ Brings cares giver to desired object or location


Please describe any other forms of communication that your child uses below:
_____________________________________________________________________________________
_____________________________________________________________________________________



I certify that the information provided in this application is truthful and
accurate.
__________________________________________________________________
Printed Name                     Signature                               Date

				
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