Street Address (required)

City (required)

State (required)

Zip (required)

Mobile Phone (required)

Home Phone

Work Phone

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25%

Who referred you to our services (name of doctor, agency, not applicable etc.)? (required)

Reason for seeking services (required)

Is your child in school? If so, list type of program (noncategorical special education, mainstream, autism classroom, not applicable, etc.)? (required)

What is the name of your child's school?

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50%

Are you seeking services in our ABA clinic, parent consultation/training, help with behaviors of concern, or school coordination/IEP support? (required)

Are there any specific behavioral concerns (tantrums, self injury, toileting difficulties, feeding issues, transitions, outings, social skills, etc.)? (required)

If problem behaviors exist, what is being done now to address them?

Do you require any special accommodations to access our services? (required)

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75%

Who does your child reside with (e.g., both parents, mother only, father only, etc.)?

What is your insurance company?(required)

Are the child’s parents married to each other?
YesNo

If the child’s parents are unmarried or divorced, we are required to know the legal guardian(s). Please specify joint custody, sole custody, etc. We will require a copy of the legal custody documents to begin services and contact the other parent in joint custody cases for joint participation. Please indicate N/A as needed.

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