New Inquiry Form

New Inquiry Form

Fill out the form carefully for registration
Child's Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Birth Date*

MonthDayYear
Gender*
Child's Age (18 months to 7 years old)*
Currently our age range for services is 18 months to 7 years old)
Does your child have a medical diagnosis of Autism?*

YesNo
Did your child previously receive ABA?*

YesNo
If yes, provide the range of dates and the names of the providers:
How would you describe your child's behavioral concerns? Please check one from the list below.*

Compliant (does not engage in any concerning behaviors)Mild/Moderate (engages in some problem behaviors such as crying, whining, tantrums)Severe (engages in high frequency of concerning behavior, such as hitting, biting, destruction)
How would you describe your child’s verbal abilities? (please choose one from the list below)*

Non-verbal (does not use words or signs to express any wants or needs)Verbal (uses some words or signs to express wants or needs)High-verbal (uses sentences to communicate and engages in conversation)
General Concerns:*
Please indicate your preference for therapy schedule in clinic*

8:00am-4:00pm4:00pm-7:00pm
Guardian Name*

First NameLast Name
Relationship*
Contact Number*
Contact E-mail*
example@example.com
Insurance Company (We accept most commercial insurance plans and select Medicaid) *
If Medicaid, please indicate which MCO*
Date*

MonthDayYear
Date
Should be Empty: