1. Please fill out the following form and click Submit

Applicant Information

1. Child's Name(required)
2. Male
3. Female
4. Date of Birth(required)
5. Parent/Guardian
6. Street Address:
7. City
8. State
9. Zip Code
10. Home Phone
11. Work/Other Phone
12. Email(valid email required)

Educational Information

1. Grade Level
2. Chronological Age
3. Current IEP Services (Check all that apply)
4. Speech/Language
5. Occupational Therapy
6. Physical Therapy
7. Adaptive Physical Therapy
8. Other:
9. In order to assist the PAC staff in making appropriate decisions, and to assist parents by making timely decisions regarding the ability of the PAC program to help their child, we would request that you send us the following information via email, us mail, or fax: 1. A copy of your child's current Individualized Education Program (IEP). 2. A copy of your child's most recent psychoeducational evaluation. 3. A copy of your child's current communication evaluation. 4. A list of your child's reinforcement preferences.

 

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Please send the requested information to: skochanowski@pyramidautismcenter.com or Pyramid Autism Center, 2830 North Glassell, Orange, CA 92865 or fax to 714-637-4027

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