Application Form

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Parent name*

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Email*

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Tel. :*

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Residential City*

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Is this your first time to join our event?*
YesNo

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How did you know about AP*
---FacebookGoogle or YahooBaiduWechatWeiboEmailEventsReferral

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Child Profile Form

Please submit the child's latest assessment report (1st page only, within 1MB)*

Please submit a recent photo of your child within 3 months(within 1MB)*

Child’s Information

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Child Name:*

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Sex:*

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Day of birth:*

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Mother Language:*

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Does your child attend school?(If applicable)

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Grade Level:

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No. of days a week:

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School timetable:

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Type of classroom:

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Current services / treatments being provided (ABA at home or school, Speech, OT etc.) :

Language Ability (please select the best answer)

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Number of words a sentence*
---1-22-33-47+

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Words knew
---0-1011-5051-100101+

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Can your child response to you?*
---YesNo

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Let us know more:

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Can your child take initiates to ask for something?*
---YesNo

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Let us know more:

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Can your child take initiates to say his/her opinions?*
---YesNo

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Let us know more:

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Can your child answer the below questions? (You May Choose More Than One)*
Who…?why…?where…?How…?None of the above

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Let us know more:

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Can your child ask the below questions? (You May Choose More Than One)*
Who…?why…?where…?How…?DepictionNone of the above

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Let us know more:

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Social Skill & Interest (please circle the best answer)

Eye contact*
---Very goodGoodFairNot goodPoor

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Can your child express his/her social needs by words/body language?*
---YesNo

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Let us know more:

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Can your child stay alone without parents?*
---YesNo

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Let us know more:

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What kind of toys, game or activities your child like to play or do in his/her free time?*

Problem Behaviors & Self-care Ability

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Does your child have self-stimulating behavior?*
---YesNo

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Let us know more:

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Can your child go toilet by himself/ herself?*
---YesNo

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If yes, how he/she show you the needs to go toilet?

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Does your child have picky eating problem?*
---YesNo

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If yes, what he/she don’t like to eat?

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Which 3 problem areas from your child you want us to tackle?*