Phoenix Contact Form
Student Name (First, Last)
Address
Student Date of Birth
Month
Day
Year
Student Diagnosis
Current Grade Level
Parent/Guardian Name (First, Last)
Parent/Guardian Name 2 (First, Last)
Primary Email Contact
Primary Phone Contact
How Did You Hear About Us?
Preferred Enrollment Date
Month
Day
Year
Do You Have Funding?
Please select any unique behaviours your student exhibits:
Self Injurious Behaviour
Separation Anxiety
Injurious Behaviour To Others
Elopement
Excessive Crying/Screaming
Throwing Items/Destructive Actions
Aggression
Please list a few of your student's reinforcers (eg. IPAD, a certain toy etc)
Is Your Learner Toilet Trained?
Yes
No
Working On It
Has Your Learner Ever Received An ODD Diagnosis?
Yes
No
Which of the following best describes your child's primary way of communicating? (Select all that apply)
Non-verbal: Relies on gestures, leading adults by the hand, facial expressions, or crying.
Vocalizations: Uses sounds but few clear words.
Single Words: Uses single words objects or to express needs (e.g., "bathroom", "ball").
Short Phrases: Combines 2 to 3 words together (e.g., "more milk", "go outside").
Complete Sentences: Speaks in full sentences, though they may make grammatical mistakes.
Fluent/Detailed: Speaks effortlessly.
Alternative Communication: Uses a device, pictures or sign language to communicate.
Please provide any additional comments or details that we should know about your learner:
Please let us know if you have any initial questions we can answer for you:
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Phoenix Contact Form