Society for Treatment of Autism
404 - 94th Avenue Calgary, AB T2J 0E8
Tel: 403-253-2291 FAX 403-253-6974
www.autism.ca
Thank you for your interest in Society for Treatment of Autism.
Society for Treatment of Autism provides individualized, intensive Early Intervention Programs funded
by FSCD and Alberta Education. We provide a developmentally appropriate, activity based, and family
focused program to support children who have a diagnosis of Autism Spectrum Disorder and their
families.
Please indicate which program you are interested in and complete the corresponding sections of the
application form:
Specialized Services and Program Unit Funding (PUF) Program
 Please Complete the following sections of the application form:
o Section A
o Section B
o Section C
o Section E
Specialized Services ONLY program
*ONLY applicable for children under 3 years of age who are not yet old enough to
qualify for PUF funding or do not have a PUF program already in place

Please
o
o
o
Complete the following sections of the application form:
Section A
Section B
Section D
Before we can process your application, we require the following documentation. Please include them
with your application.
Photo of your child
Letter of Diagnosis
Letter from FSCD outlining hours your child has been approved for Specialized Services
Most recent Assessment Reports
Most recent Individual Program Plan or Individual Service Plan (if currently in a program)
Copy of your child’s Birth Certificate
We will contact you once we have received all the required documentation.
A. GENERAL INFORMATION
CHILD’S NAME (as it appears on birth certificate):
MALE
FEMALE
CHILD’S DATE OF BIRTH (year/month/day):
BIRTH CERTIFICATE NUMBER:
ISSUING COUNTRY:
ALBERTA HEALTH CARE NUMBER:
FATHER’S NAME (S):
DATE OF BIRTH:
OCCUPATION:
ADDRESS:
(street address, city, postal code)
HOME PHONE:
MOBILE PHONE:
WORK PHONE:
EMAIL:
MOTHER’S NAME (S):
DATE OF BIRTH:
OCCUPATION:
ADDRESS: (if different than above):
(street address, city, postal code)
PHONE NUMBERS: (if different than above)
HOME PHONE:
MOBILE PHONE:
WORK PHONE:
EMAIL:
Languages Spoken within the Family Home:
Any other siblings (and their date of birth), family members or caregivers living in the home:
Please describe your family’s long-term goals for your child:
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CBO Application for Services
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B. DEVELOPMENTAL PROFILE/ MEDICAL INFORMATION
DIAGNOSIS:
DATE OF DIAGNOSIS:
DIAGNOSING PROFESSIONAL:
INTERESTS: Please describe your child’s interests:
COMMUNICATION: Please describe how your child communicates with you and other people in his/her
life (e.g., other children, extended family, etc).
BEHAVIOUR: Please list any behavioural/ safety concerns and how they are currently managed.
SELF-HELP SKILLS: Please comment on your child’s skills in the following areas:
Mealtime Skills:
Dressing:
Sleep Habits:
Toileting:
MEDICAL INFORMATION:
Family Physician:
Pediatrician:
Date of last physical examination:
ALLERGIES:
Please list any other pertinent medical information (seizure disorder, childhood illnesses, etc.):
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PROGRAMS AVAILABLE
C. COMBINED PROGRAM:
SPECIALIZED SERVICES/ PROGRAM UNIT FUNDING (PUF) PROGRAM
Society for Treatment of Autism’s combined program integrates both Specialized Services Funding and Program
Unit Funding, and runs Monday through Friday. Programming occurs in the home environment, in the
community as well as in our specialized classroom environment at Society for Treatment of Autism. Funding is
provided by FSCD for Specialized Services as well as from Alberta Education for a PUF Program. This program
serves children between the ages of 2.5 to 6 years of age. Specialized Services hours are based on the child’s
specific needs, as recommended by FSCD.
Has your child received prior Specialized Services with another agency?
No
Yes (please specify agency)
Who is your current FSCD Worker?
Is your child receiving PUF at another school?
No
Yes (please specify school)
Is your child currently attending a preschool?
No
Yes (please specify school)
Name of Preschool:
Contact Name and Phone Number:
D. SPECIALIZED SERVICES ONLY PROGRAM
Society for Treatment of Autism’s SPECIALIZED SERVICES ONLY Program is a ½ day. Children
must be under 3 years of age with NO PUF program in place.
Society for Treatment of Autism’s Specialized Services ONLY Program runs Monday through Friday.
Programming occurs in the home environment, in the community. Funding is provided by Family Support for
Children (FSCD) for Specialized Services. Hours are based on the child’s specific needs, as recommended by
FSCD.
Please specify whether you prefer:
Morning program
Afternoon Program
Has your child received prior Specialized Services with another agency?
No
Yes (please specify agency)
Who is your current FSCD Worker?
Name of Parent/ Guardian completing this form:
THANK YOU!
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E. AUTHORIZATION TO RELEASE INFORMATION
Please complete this release if you are applying for the Specialized Services and Program Unit Funding Program
I/We, __________________________________________ authorize Society for Treatment of Autism to disclose
and receive the following information about our child _______________________________.
(child’s name)


Letter of Diagnosis
Most recent Assessment Reports:
Please list which reports have been provided to Society for Treatment of Autism:
The reports/documents listed above will be submitted to Alberta Education for the purpose of applying for PUF
(Program Unit Funding) Preapproval.
I understand that this information will be disclosed and received for the purposes of determining our child’s
therapy needs and possible further treatment.
I am aware of the risks or benefits of consenting or refusing to disclose information. I also understand that I
may revoke this consent at any time. Please choose one of the following options:
This consent will expire on (mm/dd/yyyy): ___________________.
This consent will not expire except by my revocation.
Signed this __________ of __________________________ in the City of __________________.
(day)
(month)
(year)
(city)
_____________________________________
Parent Name (please print)
_____________________________________
Parent Signature
_____________________________________
Parent Name (please print)
_____________________________________
Parent Signature
_____________________________________
Witness Name (please print)
_____________________________________
Witness Signature
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