Pre-Enrollment Packet - Montessori Autism Programs and Services, Inc.

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1106 Windfield Way El Dorado Hills, Ca 95762
916-357-5837
info@mapsautism.com

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Pre-Enrollment Packet

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How to Enroll Your Child
Pre-Enrollment Packet

All clients who are interested in receiving services at MAPS need to complete the following Pre-Enrollment packet. For questions, please contact Shelby at shelbyl@mapsautism.com.

Client Pre-Enrollment Packet

Step 1 of 4

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Parent/Guardian Name*
First Last
Parent/Guardian Name*
First Last
Email*
Phone*
Patient Name*
First Last
Patient Date of Birth*
MM slash DD slash YYYY
Patient Social Security Number
Patient Gender*
Full Mailing Address*
Street Address Address Line 2 City State ZIP Code
Prescribing Physician:*
Diagnosis:*
Insurance Information
Medical Id #*
Group #*
Subscriber Name*
First Last
Subscriber Employer*
Subscriber Date of Birth*
MM slash DD slash YYYY
Insurance Company*
Insurance Self Funded*
- Yes
- No
Type:
Insurance Phone*
Is Alta Regional Center Paying for your Co-pays?*
- Yes
- No
Alta Regional Center Service Coordinator Full Name:
Alta Regional Center Service Coordinator Email:
Secondary Insurance

Release of Information
As the parent/guardian of:*
First Last
I authorize (name of Entitity or Individual-- Insurance Provider)*
Today's Date*
MM slash DD slash YYYY

to share information regarding my child with Montessori Autism Programs and Services, Inc. I am aware this information will only be shared if deemed necessary and appropriate to my child's progress with his/her program with Montessori Autism Programs and Services, Inc. and will be in effect from today's date to one year from this date.
Signature*
Parent/Guardian Name*
First Last
Today's Date*
MM slash DD slash YYYY

HIPAA Notice of Privacy Practices
By signing below, I acknowledge that I have received a copy of the HIPAA Notice of Privacy Practices.
Signature*
Parent/Guardian Name*
First Last
Today's Date*
MM slash DD slash YYYY

Client Availability
Please indicate the services you are seeking and the days and times that your child is available.
I am seeking:*
- Behavior Services
- Social Skills
Behavior Services
In-home Hours of Operation 8:00am-7:00pm
- Monday mornings 8:00am-11:00am
- Monday early afternoons 11:00am-1:00pm
- Monday late afternoons 1:00pm-4:00pm
- Monday evenings 4:00pm-7:00pm
- Tuesday mornings 8:00am-11:00am
- Tuesday early afternoons 11:00am-1:00pm
- Tuesday late afternoons 1:00pm-4:00pm
- Tuesday evenings 4:00pm-7:00pm
- Wednesday mornings 8:00am-11:00am
- Wednesday early afternoons 11:00am-1:00pm
- Wednesday late afternoons 1:00pm-4:00pm
- Wednesday evenings 4:00pm-7:00pm
- Thursday mornings 8:00am-11:00am
- Thursday early afternoons 11:00am-1:00pm
- Thursday late afternoons 1:00pm-4:00pm
- Thursday evenings 4:00pm-7:00pm
- Friday mornings 8:00am-11:00am
- Friday early afternoons 11:00am-1:00pm
- Friday late afternoons 1:00pm-4:00pm
- Friday evenings 4:00pm-7:00pm
Please select the times your child is available to receive services in home. Please select all that apply.
Center Based Hours of Operation 9:00am-6:00pm
- Monday mornings 9:00am-11:00am
- Monday early afternoons 11:00am-1:00pm
- Monday late afternoons 1:00pm-4:00pm
- Monday evenings 4:00pm-6:00pm
- Tuesday mornings 9:00am-11:00am
- Tuesday early afternoons 11:00am-1:00pm
- Tuesday late afternoons 1:00pm-4:00pm
- Tuesday evenings 4:00pm-6:00pm
- Wednesday mornings 9:00am-11:00am
- Wednesday early afternoons 11:00am-1:00pm
- Wednesday late afternoons 1:00pm-4:00pm
- Wednesday evenings 4:00pm-6:00pm
- Thursday mornings 9:00am-11:00am
- Thursday early afternoons 11:00am-1:00pm
- Thursday late afternoons 1:00pm-4:00pm
- Thursday evenings 4:00pm-6:00pm
- Friday mornings 9:00am-11:00am
- Friday early afternoons 11:00am-1:00pm
- Friday late afternoons 1:00pm-4:00pm
- Friday evenings 4:00pm-6:00pm
Please select the times your child is available to receive services at our center. Please select all that apply.
Group Social Skills
Integrated Play Group Hours of Operation 1:00pm-6:00pm
- Monday/Wednesday/Friday
- Tuesday/Thursday
Early Childhood (3-7 years old) playgroup times
- 1:00pm-2:30pm
- 2:45pm-4:15pm
- 4:30pm-6:00pm
School age (6-9 and 9-12 years old) playgroup times
- 2:45pm-4:15pm
- 4:30pm-6:00pm

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Contact

Montessori Autism Program and Services, Inc. (MAPS)
1106 Windfield Way
El Dorado Hills, Ca 95762
(916) 357-5837 office
(916) 939-4045 fax
info@mapsautism.com

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1106 Windfield Way El Dorado Hills, Ca 95762

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info@mapsautism.com

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916-357-5837

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