Day Program Registration

Thank you for your interest in our Day Program!

To help us provide the best service to our clients, please complete the following form for each individual you wish you register. ACRES staff will get in touch with you shortly.

Client's Full Name *

Date of Birth *

Age *

Client Address *

Parent/Guardian First Name *

Parent/Guardian Last Name

Parent/Guardian Address *

Email *

Parent/Guardian Phone *

Emergency Contact Name *

Emergency Contact Phone *

Relationship *

Family Members

Please list names, ages, and relationships of any family members of the client.

Client's Communication Methods *

How does the client communicate?

Verbal Non-verbal Uses some words Other

Preferred Method of Communication *

Medications *

Allergies/Food Restrictions *

Food Preferences *

Food Dislikes *

What (if any) other therapeutic services is the client recieving?

Daily Activities *

Describe the client's typical daily activities (work, school, extracurriculars, etc.)

Sensory Issues or Needs *

Aggressive Behaviors & Safety Precautions

If the client has any aggressive behaviors or requires safety precautions, please describe them here.

Interests or Hobbies

Describe the client's interests, hobbies, desired activities, likes, etc.

Triggers/Dislikes

Self-Soothing Methods

Distress Signals

Does the client display certain behaviors when stressed or uncomfortable?

Individual Goals

What are the goals of the client for this program?

Family Goals

What family goals should we work towards?

Other Notes (Optional):

Are you Human? *

Complete the captcha please.

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Day Program Registration Form

Thank you for your interest in our Day Program!