Registration form

    You can register using the form below. We currently have a waiting period of approximately six months.

    Please note: Fields marked with a * are required

    What do you want to register for?*
    Early intervention 3 to 6 yearsTreatment 7 to 12 yearsParent training

    What type of treatment?*



    Desired days/part of the day - choose a maximum of 5 parts of the day per week:



    Stap 1: Personal details of the child

    Client's first and last name*
    Nickname*
    Date of birth*
    BSN (Citizen Service Number)*
    Address
    Street and house number*
    Postal code*
    City*


    Stap 2: Contact details and family situation

    What is the family composition?* Here you indicate who your child lives with, for example the mother and 2 younger sisters, and any details about the living situation.
    First name of parent/guardian*
    Last name of parent/guardian*
    Relationship to the client*


    Mobile phone number*
    Email address*
    BSN (Citizen Service Number)*
    Type of caregiver*
    Legal authority*

    + Would you like to add a second contact person? Click here.

    Stap 3: Care request

    Who referred you to Imperium Autism Center?*

    Other, namely
    Referrer's telephone number
    Referrer's email address
    Reason for referral/registration*

    Has funding for care already been requested? Is there an indication?*

    Has there been previous assistance?*

    Are there other care providers involved in the family at the moment?*


    Which care provider is currently involved?

    Name* Email address*

    Request for assistance

    Briefly describe what the biggest concerns are for your child at the moment (think of communication, emotion regulation and stimulus processing):* Describe the requests for assistance for your child* Briefly describe the request for assistance for the parents* What results do you expect from Imperium?* During what period do you expect this result?*

    Stap 4: Risk analysis

    A scan is made during the risk analysis to take your safety and your system into account. If you have answered 'yes', this will be discussed during the intake and, if applicable, will be included in the treatment plan.
    Is there aggression?*

    Is there running away behavior?*

    Are there allergies?*

    Is there diabetes?*

    Is there epilepsy?*

    Is there medication use?*

    Are there any special features in sexual development?*

    Are there any special features regarding gender identity?*

    Are there any traumatic experiences?*

    Are there any sleep problems?*

    If yes, please explain:
    Are there any self-mutilation/self-harm?*

    If yes, please explain:
    Are there any problems with sensory stimulus processing such as auditory, visual or tactile stimulus processing?*

    Are there any psychological complaints in other family members?*

    Are there any special features in the family?*

    Are there influential people we can involve in the care process?*

    Are there any comments that are important to mention here?*

    If yes:
    Does your child have a diagnosis?*

    If yes, which ones:
    Is your child's IQ known?*


    Stap 5: Upload referral

    If you have a referral from a GP, youth counselor or neighborhood teams, we would like to receive it and you can upload it here.

    Stap 6: Consent and declaration of agreement





    Date of completion:


    Please note: you can only send if the mandatory fields (*) have been filled in, as well as the permission and declaration of agreement from Step 6.