Phone:
+7 (499) 909-86-94
E-mail: info@autismexpert.ru
help@autismexpert.ru
Address: Moscow,
Leskova str., 6b
Working time:
Mon. - Sun. (09:00 - 19:00)
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FILL IN THE FORM FOR PRIMARY INSPECTION / CONSULTATION / INTENSIVE COURSE

You can register for a primary examination for the preparation of a medical and pedagogical support program, or make an appointment for a consultation with leading specialists of the center.
The cost of a primary examination is 1,500 rubles.
We also conduct intensive rehabilitation and treatment courses for children living in other regions (from two weeks or more). To do this, you must fill in the Questionnaire for registration for the initial examination / consultation / intensive course, indicating general information and your request (classes, consultation with a specialist of a specific destination Intensive course).
After receiving the online questionnaire, our administrators will contact you. If you have any questions, you can contact us by phone +7 (499) 909-86-94 (10: 00 - 19:00 Moscow time)
Several specialists of our center lead the examination: doctors, teachers, psychologists, clinical psychologists, defectologists.
An individual program of studies at the Center, general recommendations for the development of the child is compiled.
The rehabilitation program is consistent with parents by time and by days of the week, then the child is put on the schedule for classes and consultations.

Section I. (To be completed by parents).

CONTACT DETAILS




Date of completion:

Напишите дату.

Full name of child:
(оbligatory field)(*)

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Full date of birth:
(оbligatory field)(*)

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Age at time of application:
(оbligatory field)(*)

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Address of residence (Please specify: region, city, street, house, apartment, home phone;
for Moscow in addition - the administrative district and the nearest metro station) )
(оbligatory field)(*)

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Full name of mother

Please write a subject for your message.

Mobile phone of mother

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E-mail of mother:

Please let us know your email address.

Full name of father

Please write a subject for your message.

Mobile phone of father

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E-mail of father

Please let us know your email address.

Official diagnosis:

Please let us know your message.

Information on disability (if the disability to the child is registered, please indicate: the series and reference number, the date of initial disability determination and the date of the next survey)

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What disturbs you in the condition of the child?

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Preferred days and times for attending classes in our Center

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The purpose of your visit
оbligatory field(*)


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Special wishes and comments of parents:

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PREGNANCY AND CHIDBIRTH


What pregnancy by number
(оbligatory field)(*)

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What kind of childbirth by number, the presence of brothers, sisters, their age at the time of examination, health status
(оbligatory field)(*)

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Age of mother at birth of child
(оbligatory field)(*)

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Trimester conditions
(toxicosis, infection, stress, threat of miscarriage, etc.)

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Term at birth in weeks
(оbligatory field)(*)

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Method of childbirth
(оbligatory field)(*)

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Complications of the childbirth:

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Height and weight at birth
(оbligatory field)(*)

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Score on the Apgar scale

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Diagnosis at birth

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The state of the baby in the early days after birth (1-2 month)
(оbligatory field)(*)

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Breastfeeding (how many months)

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HEREDITY


Family Diseases
(on the paternal and maternal lines: chronic, hereditary diseases)
(оbligatory field)(*)

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Allergies
(on the paternal and maternal lines, allergies in the child: what is the allergy?)

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ANAMNESIS


Past illnesses

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Postponed trauma

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Inoculations

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Consultations, treatment (including medicamentous: what drugs, when, how long)

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Accompanying illnesses

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RESEARCHES


Conducted research (dopplerography, MRI, EEG, etc. - name, date)

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I agree to processing of personal data in accordance with Federal Law №152 (оbligatory field) (*)

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When visiting a primary reception for parents It is necessary to have with you all the medical
documentation for the child (statements, results surveys and analyzes)

Before sending the Questionnaire, please make sure, that you filled in all the required fields.






About our Centre

The Scientific and Practical Center for the Rehabilitation and Treatment of Autism Spectrum Disorders is working together with the Center for the Rehabilitation of Disabled Children "Our Sunny World".

Programs and Seminars

We offer a wide range of professional training programs and seminars for all groups of professionals interacting with autism spectrum disorders.

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