Home / KIDA FORM (AGES 3-9)


Thank you for your interest in Club KIDA! If your child is between the ages of 3-9, please complete the form below. Someone will be in contact with you shortly after we receive your submission.

KIDA Registration Form ages 3-9

Child's Name*:


Child's Age*:

Child's Birthdate*:

Parent's Name*:

Phone Number:

Email Address*:


Child's Diagnosis (if any):

How did you hear about Club KIDA?

If you're interested in our Club KIDA Program, please select which session you would like:

Please list two goals that you would like your child to work on in group:*

Please identify a few of your child's interests and strengths:*

Please identify a few things that are challenging for your child:*

Has your child ever received individual occupational therapy treatment? If yes, please explain:

Has your child ever participated in social groups previously? If yes, please explain:

Does your child have any allergies? If yes, please list:

Does your child have any medical conditions (e.g. seizures) that we should be aware of? If yes, please list:

Please select the response that best represents how your child responds in each area:

Demonstrates age appropriate expressive language skills (tells his or her wants and needs)*:

Demonstrates age appropriate receptive language skills (understands simple commands/statements etc.)*:

Follow instructions/directions*:

Able to transition from preferred to non-preferred*:

Able to attend to seated activity for at least 5 minutes*:

Waits turns in games, activities and conversations*:

Speaks in an appropriate voice volume at home/school *:

Demonstrates aggressive behaviors (ie hitting, kicking, biting)*:

Demonstrates eloping (running away)*:

Shares toys/items with peers*:

Enjoys playing with others*:

Begins conversations with others (ask questions, greetings, etc)*:

Verbally (on topic) responds to peers*:

Shows an interest in others*:

Demonstrates an interest in a variety of activities/toys*:

Is physically appropriate with peers (orients body, no touching)*:

Cooperates with peers*:

Exhibits self-control in conflict situation*:

Enjoys participating in physical activities*:

Maintains eye contact with peers*:

Has a good sense of safety (Does not take excessive risks in play)*:

Please list any additional comments and/or concerns you may have regarding your child’s social skills and interactions:

Florence Clark, PhD


Florence Clark, PhD
Occupational Science and Occupational Therapy Professor and Associate Dean, University of Southern California
Florence Clark, Ph.D., OTR/L, FAOTA (Professor and Associate Dean of the USC Division of Occupational Science and Occupational Therapy) currently serves as President of the American Occupational Therapy Association. She earned her M.S. degree in Occupational Therapy from The State University of New York at Buffalo and her Ph.D. in Education from the University of Southern California.

A widely published and noted scholar, Dr. Clark’s research over the last two decades has largely centered on the relationship of everyday activity engagement to health and wellness. Appointed as a charter member of the Academy of Research of the American Occupational Therapy Association, Dr. Clark has served as special consultant to the U.S. Army Surgeon General, been on the board of the National Center for Medical Rehabilitation Research and been the recipient of an Eleanor Clarke Slagle Lectureship.

Additionally, she is a member of the Autism Advisory Task Force for the California Department of Managed Care, which is charged with developing recommendations regarding medically necessary health treatments for individuals with autism.

Matthew Goodwin, PhD

Matthew Goodwin, PhD
Assistant Professor, Dept. of Health Sciences Northeastern University
Professor Goodwin, Ph.D. is an interdisciplinary faculty member affiliated with the College of Computer and Information Science and the Department of Health Sciences at Northeastern. He co-directs the joint-college doctoral program in Personal Health Informatics and has nearly two decades of research and clinical experience working with the full spectrum of children and adults with ASD.

He is well acquainted with a variety of experimental methods and statistical approaches used in the behavior sciences and has extensive experience developing and evaluating innovative technologies for behavioral assessment, including telemetric physiological monitors, accelerometry sensors, and digital video/facial recognition systems.

Before joining Northeastern, Professor Goodwin served as director of clinical research at the MIT Media Lab, where he continues to co-direct their Autism and Communication Technology Initiative. He received his B.A. in Psychology from Wheaton College in 1998 and his M.A. in 2005 and Ph.D. in 2008, both in Experimental Psychology, from the University of Rhode Island.


Christy Hom, PhD


Christy Hom, PhD
Pediatric Neuropsychology UCI School of Medicine
Dr. Hom received a BA in Psychology with a concentration in Developmental Disabilities from UCLA and a Ph.D. in Clinical Psychology from the University of Michigan, Ann Arbor. She completed a post-doctoral fellowship in Health Psychology at Children’s Hospital of Orange County.

She is currently an Assistant Clinical Professor at UC Irvine in the Department of Psychiatry and Human Behavior. She has been working with children with developmental disabilities and their families in both research and clinical settings since 1992.

She was an ABA therapist at Johns Hopkins University’s Kennedy Krieger Institute, coordinated several research studies at UCLA regarding the impact of a developmentally disabled child on the family and cultural differences in beliefs about developmental disabilities, and has been the coordinator of UC Irvine’s Neurodevelopmental and Behavioral Clinic since 2007.


Ira Lott, MD


Ira Lott, MD
Board Certified: Pediatrics, Neurology with Special Qualifications in Child Neurology
An expert in child neurology, Dr. Lott’s primary research focus is in the neurology of developmental disabilities. He is the director of the Scientific Advisory Board of the National Down Syndrome Society in New York and has received the national research award from the Down Syndrome Society and the Christian Pueschel Memorial Research Award from the National Down Syndrome Congress. In addition, he received the Spotlight Award from the California State Senate for his work with the developmentally disabled.

Recognized nationally as an expert in developmental disabilities, Dr. Lott has been invited to be a member of the Developmental Biology Study Section for the Eunice Kennedy Shriver National Institute for Child Health and Human Development, NIH/NICHD to serve a term between 2011-2015.

Dedicated to clinical excellence, Dr. Lott is board certified in pediatrics, psychiatry and neurology with special competence in child neurology. He attended medical school at Ohio State University College of Medicine graduating with honors. Dr. Lotts completed his internship and residency in pediatrics at Massachusetts General Hospital, Boston, MA. Dr. Lott served his residency in child neurology at Massachusetts General Hospital. Dr. Lott is consistently voted as one of Orange County’s Top Doctors by the Orange County Medical Association.

David Monkarsh, PhD


David Monkarsh, PhD
Clinical Psychology Autism Specialist
Dr. David J. Monkarsh is a Clinical Developmental Psychologist who has specialized in the diagnosis and treatment of individuals with autism since 1982. His clinical practice focuses upon training children and their families in ways to facilitate social adaptive behavior and self-regulation across diverse settings.

By promoting increased self-understanding and the understanding of others, Dr. Monkarsh works to help children with autism develop strategies for acquiring skills that enhance personal competence and community integration. In addition to his private practice, Dr. Monkarsh has been an Assistant Clinical Professor of Pediatrics at the UCI Medical Center since 1982.

Gail Fernandez, MD


Gail Fernandez, MD
Child Psychiatry UCI School of Medicine
Dr. Fernandez received undergraduate degrees in Psychology and Biology at the University of California, Irvine. She continued on to medical school at Creighton School of Medicine in Omaha, Nebraska, completing her medical training in 1991. She completed both general psychiatry residency and child psychiatry fellowships at Creighton/UNMC Department of Psychiatry, graduating in 1996.

She joined the faculty at University of California, Irvine in 1996 and now serves as Program Director for the Child and Adolescent Psychiatry Fellowship and Vice Chair for the Department of Psychiatry. She also works as Medical Director of the Adolescent Psychiatry Inpatient Unit, an acute care program for psychiatrically ill children and adolescents ages 12-18.

She works with the Center for Neuropsychiatric Studies, a multidisciplinary research and evaluation project in collaboration with the Regional Center of Orange County. Several studies have been published as a result of this collaboration. She is Board Certified in General Psychiatry (recertified in 2006) and Child and Adolescent Psychiatry (recertified in 2007).

Linda Smith, RN, BSN, PHN


Linda Smith, RN, BSN, PHN
CEO Providence Speech and Hearing Center
Linda began her career as a registered nurse with a public health nursing credential from Mount St. Mary’s College. Since then, she has continued to work in healthcare, including holding various senior level positions with TrinityCare LLC and Little Company of Mary Health Services.

Linda was also a founder of LifeCare Solutions/Nations Healthcare, a home infusion company, and ran her own healthcare consulting firm for five years before moving to Providence. Since joining Providence in 2007, the organization has grown to 7 locations and $19 million dollars in revenue.

Maria Minon, MD


Maria Minon, MD
General Pediatrics Chief Medical Officer, CHOC Childrens
Dr. Maria E. Minon, a native of Buenos Aires, Argentina, currently serves as the Vice President, Medical Affairs and Chief Medical Officer for CHOC Children’s, a position she has held since 1998.

As Vice President of Medical Affairs and Chief Medical Officer, Dr. Minon works to facilitate and oversee the activities of the Medical Staff, Medical Quality and Patient Safety, Psychology Training Program, Graduate and Continuing Medical Education, CHOC’s Heart, Neuroscience, Orthopaedic and Cancer Institutes and Clinical and Basic Science Research Departments.

Dr. Minon achieved her Medical Degree at University of California, Irvine and completed her post-graduate training at UCI Medical Center and Children’s Hospital of Orange County, where she was appointed Chief Resident. She holds a faculty position at UCI as Associate Clinical Professor of Pediatrics. Dr. Minon worked in private practice for general pediatrics and adolescent medicine from 1979 to 1998.

Matthew Peterson, PhD


Matthew Peterson, PhD
Cofounder, CTO and Senior Scientist MIND Research Institute
Matthew Peterson, Ph.D., is Cofounder, CTO and Senior Scientist at the MIND Research Institute, a non-profit education and research organization. His focus is on developing interactive visual learning environments that enable students to gain a deep conceptual understanding of mathematics regardless of language proficiency.

Matthew, who as a child struggled with traditional language-based instruction due to dyslexia, created MIND’s ST Math software to teach math to students utilizing his unique non-language based visual approach. He did undergraduate work at UC Irvine and his doctoral work in visual neuroscience at UC Berkeley.

Rosalind Picard, ScD


Rosalind Picard, ScD
Co-Director, Autism Communication Technology Institute MIT Media Lab
Professor Rosalind W. Picard, Sc.D. is founder and director of the Affective Computing Research Group at the Massachusetts Institute of Technology (MIT) Media Laboratory, co-director of the Things That Think Consortium, the largest industrial sponsorship organization at the lab, and leader of the new and growing Autism & Communication Technology Initiative at MIT.

She is co-founder, chief scientist and chairman of Affectiva, Inc., making technology to help measure and communicate emotion. Picard holds a bachelor’s degree in electrical engineering with highest honors from the Georgia Institute of Technology, and master’s and doctorate degrees, both in electrical engineering and computer science, from MIT. Picard is an international leader in envisioning and inventing innovative technology.

She holds multiple patents, having designed and developed a variety of new sensors, algorithms, and systems for sensing, recognizing, and responding respectfully to human affective information, with applications in autism communication, human and machine learning, health behavior change, marketing, advertising, customer service, and human-computer interaction.

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