Child's Name

Male Female         Date of Birth

Parent / Guardian

Mailing Address: Street Address

City  State Zip Code

Home Phone:  Work/Other Phone:

E-Mail Address

Current School District

Grade Level    Chronological Age

Current IEP services (check all that apply):

Speech/Language Occupational Therapy Physical Therapy 

Adaptive Physical Therapy Other

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.

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