Parents of Children all Ages with ASD & Executive Functioning Issues Group 2016

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* 1. Please fill out the information below.

First Name

Last Name

Email

Phone Number

Address (including city, state, and zip code)

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* 2. Are you a parent/guardian of an individual diagnosed with an Autism Spectrum Disorder?

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* 3. Does the individual(s) diagnosed with ASD also have other diagnoses? If so please list below.

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* 4. Is the individual a current client at ECG? If so who does he/she see? If they are not a current client at ECG, who do they see or meet with for support?

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* 5. We ask that you attend at least 10 out of 12 weeks of group that meet Saturday April 8, 2017 through Saturday June 24, 2017. (understanding that emergencies may arise). Would you be able to attend group every Saturday from 2:00p.m-3:30p.m? If both parents are coming, we ask that you both commit to 10 out of 12 weeks. Please answer below.

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* 6. The cost of this group may be covered by your insurance, with exception of a co-pay. We will be happy to check your benefits for you. Please provide us with the following information. (mark N/A if you are not covered by major medical.)

Name

Date of Birth

Name of Insurance Company

Insurance Company Contact Number

Member ID #

Group #

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* 7. If you are not covered by a major medical insurance, the cost for group will be $30.00 per session. Will you need assistance/sliding scale?

Yes, I'd like to request sliding scale.

No, I will self pay at $30 a session.

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* 8. Do you have any other comments, questions, or concerns?