Vista Autism Center | SimplePractice

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First name

Last name

Phone

Date of birth

State

Select the state you live in

Religion, if applicable

Child or Client's Place of Birth

Caregiving of child or individual receiving care

Child is in foster care Child is adopted Child is in kinship care None apply

Parent/ Guardian 1 Full Name (If client is over age 18- enter own name)

Parent/ Guardian 1 Email Address (If client is over age 18- enter your own email)

Parent/ Guardian 1 Phone Number (if client is over age 18- enter your own number)

Parent/ Guardian 2 Full Name

Parent/ Guardian 2 Email Address

Parent/ Guardian 2 Phone Number

Home address of child or individual seeking care

Child or individual resides with:

Parent/ Guardian 1 Parent/ Guardian 2 Both Other The individual seeking care lives independently

Please list the ages and genders of any siblings or other children in the home.

Limited to 600 characters

Child/ Client's School (if applicable)

Child/ Client's Grade in school (if applicable)

Is the child/ client presently taking any prescription medications? If so, please list below.

Does the child/ client have any physical health problems or disabilities? If so, please list below.

Limited to 600 characters

Please provide the full name of an emergency contact and their phone number below.

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.

Who would be receiving care?

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