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Koegel Autism Center Assessment Clinic
University of california santa barbara
Santa Barbara, CA 93106-9490 / Phone (805) 893-2049
Fax: (805) 893-2658
KOEGEL AUTISM CENTER ASSESSMENT CLINIC REGISTRATION FORM
Please type in the requested information in the gray text boxes
CLIENT INFORMATION / PARENT/GUARDIAN INFO (if applicable)Full Name / Full Name
Sex / Relationship
Age / Spouse’s Name
CONTACT INFORMATION
Home Phone / Home Address
Cell Phone / City, State, Zip
Work Phone / Best Time to Contact
Email / Preferred Contact Method
SUPPLEMENTAL INFORMATION
Briefly describe why you are seeking an evaluation.
How did you hear about the assessment clinic?
Do you have the parental/guardian/conservator/legal rights to authorize this assessment? Yes No
Are there any current or upcoming legal/custody cases involving the individual to be assessed? Yes No
EMAIL USE CONSENT (OPTIONAL)
Should you agree to this email use consent, you and the staff of the Koegel Autism Center are agreeing to correspond using electronic mail (email). Please note the following guidelines for the intended use of this type of communication:
Email is generally considered an insecure form of communication. Consider email like a postcard that can possibly be viewed by unintended parties. Because of these security concerns, email should only be used for non-urgent, non-sensitive matters. Types of information appropriate for email include: appointment scheduling and confirmation, inquiries about general clinic policies and waitlist information, and cancellation notifications. You may submit this registration form via email should you choose, but again, be aware of that any sensitive information included could possibly be viewed by unintended parties. The Koegel Autism Center cannot communicate results of mental health assessment evaluations or treatment via email. When composing an email, be aware that the Koegel Autism Center may not be able to reply to it immediately. Should you require a more immediate response, please call us at (805) 893-2049 during regular business hours. Either you or the Koegel Autism Center may request via email or letter to discontinue using email as a means of communication.
If you agree to this email use consent form, please type your full name as your electronic signature: / Name: / Date:
SUBMITTING THIS FORM
After completing this form, there are several options for submitting it to us:
EMAIL:
FAX: (805) 893-2658
MAIL: Koegel Autism Center Assessment Clinic
Gevirtz Graduate School of Education
University of California, Santa Barbara,
Santa Barbara, California 93106-9490