LCPC, CAS, CERTIFIED AUT-PLAY

Forms

If you are an adult seeking services for yourself, please download and complete the forms below and bring them with you to your first appointment.  

If you are unsure how to answer any of the questions, leave it blank.

KCCS adult consent.docx

KCCS adult intake final.docx

KCCS brief checklist.docx


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If you are seeking services for a minor or someone with a guardian, please download and complete the forms below and bring them with you to your first appointment. 

If you are unsure how to answer any of the questions, leave it blank.

KCCS intake final.docx

KCCS minor, da consent.docx


If you are seeking services for a person diagnosed with an Autism Spectrum Disorder, please download and complete the forms below and bring them with you to your first appointment.

If you are unsure how to answer any of the questions, leave it blank.

         For children aged 3 to 11          

KCCS intake final.docx

KCCS minor, da consent.docx

AutPlay Assessment of Play.pdf

AutPlay Child Observation Form.pdf

AutPlay Connection Inventory Child.pdf

AutPlay Emotional Regulation Inventory Child.pdf

AutPlay Parent Self Care Inventory.pdf

AutPlay Situation Behavior Assessment.pdf

AutPlay Social Skills Inventory Child.pdf

AutPlay Unwanted Behaviors Assessment.pdf


          For adolescents age 12-18

KCCS intake final.docx

KCCS minor, da consent.docx

AutPlay Unwanted Behaviors Assessment.pdf

AutPlay Social Skills Inventory Adolescent.pdf

AutPlay Situation Behavior Assessment.pdf

AutPlay Parent Self Care Inventory.pdf

AutPlay Emotional Regulation Inventory Adolescent.pdf

AutPlay Connection Inventory Adolescent.pdf





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