Application for 3-Day Conscious Connection Intensive

Application for 3-Day Conscious Connection Intensive

Vistas Autism Consulting, LLC ~ www.vistasac.com ~ 561.635.6105
Name of Parent(s) *
Name of Child *
Birth date of Child (mm/dd/yyyy) *

/ Month / Day Year

Address

Phone Number

- Area Code Phone Number
E-mail *
Diagnosis
Please describe any therapies or medications your child is currently using or has used in the past
Please describe the makeup of your household (parents, sibliings, nanny, other relative, pets living there)
Tell me what your child's typical week is like
What are your child's strengths?
At present, how interested is your child in interacting with you?
How would you describe your child's communication with you?
What would you most like to see change or improve for your child and family in the next 3 to 6 months?
What are you hoping to learn from this intensive experience?
Should be Empty: