Parent or Guardian Name *

Please type the first and last name of the primary caregiver.

First Name

Last Name

Parent of Guardian Phone *

Please type the phone number of the primary caregiver.

(###)

###

####

Client Name *

Please type in the client's first and last name.

First Name

Last Name

Client Date of Birth *

Please type in the client's date of birth.

MM

DD

YYYY

Client Address *

Please type in the client's address.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

School Attendance *

Please specify whether the patient attends school yet or not.

Yes

No

Formal Diagnosis of Autism *

Please specify whether your child has an official autism diagnosis at this time. This evaluation is typically run by a child psychologist, pediatric neurologist or developmental pediatrician. A pediatrician or primary care provider can only run a screening, not a formal diagnosis.

Yes

No

I don't know

Primary Care Provider Name *

Please specify your child's primary care provider information.

First Name

Last Name

Primary Care Provider Address *

Please specify your child's primary care provider information.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Care Provider Phone *

Please specify your child's primary care provider information.

(###)

###

####

Payment Method *

Please select your method of payment.

Self-Pay (100% BCBA-led treatment)

Department of Education Funding

Health Insurance Funding

Other

Services Of Interest *

Please select the services you are interested in.

One-On-One ABA Therapy

Caregiver Training

Social Skills Group

One-On-One Speech Language Pathology

One-On-One Occupational Therapy

One-On-One Physical Therapy

Diagnosis

Medical Follow-Up

Other

Adaptive and/or Self-care Skills *

Does your child require assistance with the following skills?

Eating

Bathing

Dressing

Brushing Teeth

Safety Skills

Other

N/A

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