Application form for services from Perseus Learning Center

Please complete the following information

Thank you for your interest in Perseus Learning Center! We are currently accepting applications for children 18 months or older, with very limited space available. If you are interested in more information please reach us by submitting a contact form.

To apply for our program, please fill out any information below that you feel comfortable sharing with our specialists. After we receive your application, our team will be in contact in 1-2 business days to confirm we've received your information and schedule a tour. All information is kept in strict confidentiality, is HIPPA compliant, and will only be used internally by our specialist to help determine if our center is the perfect fit for your child.

General Information - Step 1 of 12

Name *

Email Address *

Phone Number

What location are you interested in? *

Child Information

Child's First Name

Child's Last Name

Child's Gender

Child's Birth date

Child's Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Guardian Information

Primary Guardian title

Primary Guardian Full Name

Must provide proof of guardianship.

Primary Guardian Email

Primary Guardian Primary Phone Number

Primary Guardian Primary Phone Number field

Primary Guardian Secondary Phone Number

Primary Guardian Secondary Phone Number field

Primary Guardian preferred method of contact

Contact me by Email
Contact me by Text Message
Contact me by Phone Call

Check all that apply.

Primary Guardian address

Primary Guardian Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact Information and Protocol

List emergency contacts different from the guardians who are authorized for pick up:

#1 Name:

#1 Phone Number:

#2 Name:

#2 Phone Number:

#3 Name:

#3 Phone Number:

In an emergency, I give consent for evaluation and treatment as described:

The administration of any first aid and/or medical treatment deemed necessary by a medical professional.
The transfer to the closest hospital or clinic when medically necessary and when a guardian cannot be reached.
The administration of CPR/First Aid by trained school staff.

Secondary Guardian Information

Secondary Guardian title

Secondary Guardian Full Name

Must provide proof of guardianship.

Secondary Guardian Email

Secondary Guardian Primary Phone Number

Secondary Guardian Primary Phone Number field

Secondary Guardian Secondary Phone Number

Secondary Guardian Secondary Phone Number field

Secondary Guardian address

Secondary Guardian Address

Address Line 1

Address Line 2

City

State

Zip Code

Child's Family History

List family members and their age & relationship who reside with your child.

List any other household members (non-family) who reside with your child.

Is your child adopted?

What age were they adopted?

Do they know they are adopted?

Are parents separated or divorced?

Date of separation or divorce

What was the child's age at the time of the separation or divorce?

What languages are spoken in the home?

What community resources is your child or family currently utilizing?

Please list any community resources, such as support groups, social services, school based services, or other social supports.

Child's Medical Information

Does your child have a Primary Care Physician?

Name of your child's Primary Care Physician:

Phone number of your child's Primary Care Physician:

Address of your child's Primary Care Physician:

Address Line 1

Address Line 2

City

State

Zip Code

Does your child have a medical autism diagnosis?

When was your child diagnosed? *

Where was the diagnosis conducted? *

Name of diagnosing physician? *

Does your child have any other diagnoses?

What are your child's other Diagnoses?

Medical History

Please provide known medical conditions, dates and providers of previous treatments, current treating clinicians, and any childhood illnesses, including the ages any illnesses occurred.

Does your child have any current medical or mental health conditions which may directly impact treatment or require a staff member to intervene?

Please explain any health conditions which which may directly impact treatment or require a staff member to intervene:

Does your child have any allergies?

Please explain the allergies:

Is your child currently taking medication?

Please explain the medications including the purpose, the dosage, the route, frequency, and possible or observed side effects:

Will your child require medication administration while at the Learning Center?

Please explain the medications including the purpose, the dosage, the route, frequency, and possible or observed side effects:

Has your child been hospitalized for any reason?

Please explain the hospitalization:

Over the Counter Medication administration:

Tylenol
Ibuprofen
Hydrocortisone Cream
Cough Drops
Antacid tablets
Antibiotic ointment
Benadryl

Please check the box of each approved Over the Counter Treatment for your child:

Child's School History

Where does your child currently attend school?

What is your child's current school placement?

What is your child's weekly school schedule like?

What type of school does you child currently attend?

Nonpublic
Public
Private
Charter

What is the current type of program at your child's school?

Full-inclusion classroom
Full-inclusion classroom with resource pull-out
Self contained class
Self contained class with some mainstreaming

Check all that apply.

Please check any current educational concerns:

Difficulty reading
Difficulty spelling
Difficulty with school attendance
Difficulty with abstract concepts
Difficulty with handwritting
Difficulty with arithmetic
Difficulty maintaining attention
Difficulty with organization

Check all that apply.

Does Your child have an IEP? *

What is the IEP primary category?

Tuition

Perseus Learning Center is a Private Institution. Yearly tuition covers:

Experienced and certified classroom teachers who work closely with our Board-Certified Behavior Analyst and parents to create individualized academic goals for each child.

Educational programs that include but are not limited to:

Social Skills
Life Skills
Math
English Language Arts
Fine and Gross motor skill development
Music and Movement
Science
History
Year-round academic and therapeutic services that including our Summer Program each June and July.

Additionally, tuition also covers teachers and Behavior Technicians who constantly work together to establish a nurturing learning environment where innovation, creativity, and mentorship promotes growth in all areas of life for our clients.

Tuition Per Year per Child:

Pre-Kinder tuition:	$4,000
Kinder tuition:	$14,000
1st-12th tuition:	$28,000

I understand the information that has been listed above on this page

Child's Service History

Is your child currently receiving or have received any ABA Therapy or other intensive Autism related services?

Please explain any current or past ABA Therapy or other intensive Autism related services, including dates of service:

Is your child currently receiving or have received any speech and language therapy?

Please explain any current or past speech and language therapy, including dates of service:

Is your child currently receiving or have received any behavioral health or mental health services?

Please explain any current or past behavioral health or mental health services, including dates of service:

Please provide the name of clinician and their contact information, such as phone number and address.

Is your child currently receiving or have previously received any occupational therapy?

Please explain any current or past occupational therapy and responses, including dates of service:

Is your child currently receiving or have previously received any educational therapy or tutoring?

Please explain any current or past educational therapy or tutoring, including dates of service:

Child's Skill and Needs

Challenging Behavior:

Aggression (hurting others)
Self-Injurious Behavior (hurting themselves)
Property Destruction
Crying/Screaming
Vocal Protest (arguing/refusing to do things
Elopement (running away)
Tantrums
Stereotypy (repetitive vocalizations or motor movements that interfere with learning or social opportunities)

Check all that apply.

Describe your overall concerns for the child:

Please provide a brief description of your child's communication skills:

What do your child's self-care skills look like (e.g. hand washing, dressing, feeding, toileting, hygiene tasks)?

Please provide a brief description of your child's play skills:

Social skills:

My child prefers to do things on his/her own rather than with others.
My child prefers to do things the same way over and over again.
My child notices small sounds when others do not.
In social groups, my child struggles to keep track of several different peoples' conversations.
My child finds social situations difficult.
When my child talks, it isn't always easy for others to get a word in edgewise.
It upsets my child if the daily routine is disturbed.
My child finds it difficult to "read between the lines" when someone is talking about them.
New situations make my child anxious.

Check all that apply.

Food sensitivities:

My child will eat the food I present.
My child will try the food I present.
My child eats a variety of flavors.
My child would prefer to eat the same foods every day.
My child prefers to eat liquid based foods.
My child insists on eating a particular brand.
My child insists on visiting a particular restaurant every week.
My child engages in challenging behavior when new foods are presented.
When presented a similar food but different brand my child engages in challenging behavior.
When presented a non-preferred food my child engages in challenging behavior.
I have to plan my day and meals around my child's food preferences.
There have been previous food interventions.
There are foods my child refuses to eat.

Check all that apply.

Current toileting skills (e.g., wears a diaper, uses toilet to urinate when taken on a schedule):

Describe your child's strengths:

How does your child prefer to spend his/her downtime?

List any extracurricular activities your child is involved in:

Describe your child's social relationships at home and at school:

Please describe any behavioral or attention problems that have been brought to your attention by the school staff:

What are some of your child's most preferred items they enjoy?

Is there any additional information you feel would be helpful in evaluation of your child?

Health Insurance Information / Policy Holder Information

Name of the insurance your child will be using:

Name of the Policy Holder:

Date of Birth Policy Holder:

Gender of the Policy Holder:

Male
Female
Non-binary

Relationship to Child:

Email Address:

Primary Insurance Carrier:

Insured Employer:

Insurance Phone Number:

Member ID #

Group / Plan #

Do you have a Secondary Carrier?

Secondary Carrier Name:

Secondary Carrier Member ID #

Secondary Group / Plan #

Secondary Insurance Phone Number