intake NEW Triple Beneficiary Name * Beneficiary ID Number * Beneficiary's Age * Less than 5 years From 5 to 12 years From 12 to 18 years Over 18 years Parent's Triple Name * Contact Number * Email Has he/she been diagnosed with autism spectrum disorder or a developmental disorder? * Yes No Upload a diagnostic report upload file from here choose file Maximum file size: 5MB Has the hearing test been performed? * Yes No Upload a hearing test report upload file from here choose file Maximum file size: 67.11MB الخدمات التأهيلية المرغوبة: (يمكن اختيار خدمة واحدة فقط) * استشارة مجانيةمشاكل الإطعام وانتقائية الطعامالتقييم النمائي الشاملالخدمات المنزليةالبرنامج التأهيلي المكثفالتأهيل المهنيالباقة الواحدة (24 جلسة في علاج التخاطب واللغة أو العلاج الوظيفي)تدريب الأسرة عن بعدالمشاكل السلوكية الشديدة والتواصل الوظيفي (24 جلسة)برنامج التهيئة للمدرسة Payment Method * Cash Insurance (Tawuniya) Insurance (Bupa) Insurance (Malath) Insurance (MidGulf) Has the beneficiary been registered with Autism Center of Excellence previously? * Yes No How did you learn about the Autism Center of Excellence and its services? * Through social networkingThrough a friendThrough a previous beneficiary of the center’s servicesThrough one of the center’s employeesOther How did you learn about the Autism Center of Excellence and its services? Please enter employee ID number * ارسال If you are human, leave this field blank.
