U N I V E R S I T Y O F C A L I F O R N I A , S A N TA B A R B A R A
BERKELEY • DAVIS • IRVINE • LOS ANGELES • MERCED • RIVERSIDE • SAN DIEGO • SAN FRANCISCO
KOEGEL AUTISM CENTER ASSESSMENT CLINIC
UNIVERSITY OF CALIFORNIA SANTA BARBARA
SANTA BARBARA, CA 93106-9490
SANTA BARBARA
• SANTA CRUZ
PHONE (805) 893-2049
FAX: (805) 893-2658
autismassessment@education.ucsb.edu
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
Sex
Age
Full Name
Relationship
Spouse’s Name
CONTACT INFORMATION
Home Phone
Cell Phone
Work Phone
Email
Home Address
City, State, Zip
Best Time to Contact
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?
Are there any current or upcoming legal/custody cases involving the individual to be assessed?
Yes
Yes
No
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:
SUBMITTING THIS FORM
After completing this form, there are several options for submitting it to us:
EMAIL:
autismassessment@education.ucsb.edu
FAX:
MAIL:
(805) 893-2658
Koegel Autism Center Assessment Clinic
Gevirtz Graduate School of Education
University of California, Santa Barbara,
Santa Barbara, California 93106-9490
Date: