Full Name Date of Birth Gender Male Female Non-binary Prefer not to say Other

Parent/Guardian Name (if applicable) Contact Number Email Address Address

Primary Concerns / Reason for Intake Has there been a previous diagnosis of Autism Spectrum Disorder? Yes No Unsure If yes, by whom and when?

Relevant Medical History Current Medications (if any)

Educational Background Current Services/Supports (e.g. therapies, special education)

Strengths / Interests

Challenges / Areas of Difficulty