CLASS ACTION SUIT
INTENSIVE EARLY INTERVENTION PROGRAM
PRELIMINARY REGISTRATION




PART I-Identification









CHILD










Last Name :  ______________________________   First Name_________________________






Date of birth : Day____________ Month :____ Year :_______   Age : __________






Gender : F___  M___  Diagnosis  :___________________________________________

 























FATHER










Last Name :  ______________________________   First Name_________________________





Address : _________________________________________________________





City : ____________________________________________    Postal Code : ______________





Tel. Home :(        ) ______-________   Tel. Work : (        ) ______-________



E-mail address : _________________________________________________

























MOTHER










Last Name :  ______________________________   First Name_________________________





Address  (if different from the father) :  _______________________________________





City : ____________________________________________    Postal Code : ______________





Tel. Home :(        ) ______-________   Tel. Work : (        ) ______-________



E-mail address : _________________________________________________



























N.B. (part 1-identification)

Please be assured that the information you have provided  will be kept confidential and will only be used to communicate with you in the future. This information will also be provided to the designated lawyer for the class action suit.


Please identify the person to whom we should send any correspondence:  : ___________________________________________________________________________ 

















PART II



EVALUATION QUESTIONNAIRE

Preliminary information






    


  1. At what age was your child diagnosed?
    2. 

    
________________________________________________________________
    

  2. Was your child hospitalized in order to perform the diagnosis?
    

    ________________________________________________________________
    3. 

  3. Have you incurred personnal expenses in order to obtain intensive early intervention    treatment program  for your child?
    

    ________________________________________________________________
    4. 

  4. If so, please provide a brief description of the services that you have paid for and  an estimate of their costs.
    

    ________________________________________________________________
    

    ________________________________________________________________
    

    ________________________________________________________________
    

    ________________________________________________________________
    

    ________________________________________________________________
    

    ________________________________________________________________
    

    ________________________________________________________________
    

    5. 











The information you have provided in the previous sections will be forwarded to the designated lawyer for the class action suit. Please do not feel obligated to complete this questionnaire.



I authorize Carole Ladouceur to forward the content of this document to the designated lawyer for the class action suit.

















_______________








____________________________













Date








Signature











Mail to : 

FQATED


65, rue de Castelnau Ouest

local 104

Montréal, Québec

H2R 2W3

E-mail address to join us: recours_autisme@hotmail.com