Client Initial Interest Form

Client Interest Form
Dear parents, caretakers, and families,

Thank you for your interest with Snowflakes ABA! If you are a returning family, welcome back! Please complete take about 1-3 minutes to complete this initial interest form for families seeking services for their child ("client"). Please note the following
- Complete one form for each child, as needed.
- We have generally more daytime availability than afterschool and evening, due to clinician preferences and availability preferences
- If you have a strict requirement that the RBT be of a certain gender, please answer that question below. Note: Most families do not have a gender requirement.
If Snowflakes can accept your child for services, we will follow up with formal intake and onboarding. If we cannot serve your child immediately, we will place your child on our waitlist.

Best regards,

Snowflakes ABA, LLC
You and Your Child
Parent's name*

First NameLast Name
Parent's email*
example@example.com
Parent's phone*
Please enter a valid phone number.
City/Town
Zip Code
Child's name

First NameLast Name
Child's age*
Child's Birthdate*

MonthDayYear
Date
Does your child have a diagnosis for autism?*

YesNot yet / In progressUnsureNoOther
Insurance

Note: We currently accept CareFirst, Kaiser, and Medicaid. We expect to accept Aetna later in 2025. If we do not yet accept your insurance, please continue completing the form. Families will be contacted from our waitlist in the order inquiries are received once we begin accepting additional plans.
Insurance(s)*

AetnaAnthemCarefirstCignaKaiserMedicaidPrivate PayTricareUnitedHealthcareOther
Other Insurance: If other, what insurance(s) do you have?
Availability

Note: We have generally more daytime availability than afterschool and evening, due to clinician preferences and availability preferences
What hours of availability do you have for your child? Select all that you can do:*

Mornings (9-12p)Afternoons (12-3p)After-school (3p-6p)Evenings (6-9p)WeekendsOther
Additional Information
Former client: Is this child a former client of Snowflakes ABA?

YesNoOther
Gender Requirement for RBT: Do you have a strict gender requirement for the RBT?

Must be maleMust be femaleNo requirement
Any other comments or notes?
Form completed by

ParentOther family memberSnowflakes StaffReferring ProviderOther
Referral
How did you hear about Snowflake ABA?

Another parent/familyKennedy KriegerPhysician (please name below)Google searchGoogle Maps searchSpeech Language Pathologist (SLP)Other
Please name your physician or referral source.
Thank you for your interest in Snowflakes ABA!
Should be Empty:

Client Interest Form

You and Your Child

Insurance

Availability

Additional Information

Referral