Pre-Registration Form Child's Name Child's Birthdate Parent(s) Name(s): Address: Home Phone: Work Phone: Email Address (required) Diagnosis, Date Diagnosed, and By Whom (detail please): In current ABA program? YesNo Name of ABA program: If yes, how long? What school system is your child involved in? Insurance Carrier: How did you find out about ALC? All information given to ALC, including this form, is confidential.