Course Registration Form

Free ABA Telehealth Registration

Please fill out this form with as much detail and as honestly as possible. We reserve the right to withdraw services if it is found that answers were fabricated or the circumstances have changed.
Student Name

First Name Middle Name Last Name
Birth Date

Month Day Year
Gender
Address

Street Address

Street Address Line 2

City County

Postal Code Country
Contact E-mail *
Mobile Number *
Is your child in education?

Yes, nursery/preschool Yes, mainstream school Yes, special needs school Yes, private school No
Does your child have an EHCP?

Yes In the process No
What electronic tablet/laptop devices do you have at home? *
Do you have internet access at home? *
What is the profession of the parent/guardian? *
Have you tried ABA before? *
How did you hear about ABA Horizons? *

Facebook Email Word of mouth
Some learners need more assistance from their parent/guardian during telehealth sessions. How many hours a week do you have to dedicate to this program? *
10% of telehealth ABA service hours will have to be overseen by a BCBA supervisor, this is to ensure we are working towards the correct targets and making progress, if we are not, adjustments can be made. The cost of this is £60 an hour. For example, if your child receives 10 hours of FREE ABA services, you will need to pay £60 for one hour of supervision. Do you agree to this aspect?
Can we contact you via the email and/or phone number you provided? (we never sell your data on to any third parties)
Additional Comments/Questions
Please verify that you are human *
Thank you very much for taking the time to fill out this form, someone will be in touch soon. If you are elgible for the free hours and there are slots availiable still, we will arrange a phone consultation to ask some further questions about your child.

If you have any questions in the meantime, please reach out via email awells@abahorizons.co.uk.
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Free ABA Telehealth Registration