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

  • Format: (000) 000-0000.
  • Child's Birthdate*
     - -
  • Does your child have a diagnosis for autism?*

  • Coordination of Benefits

    Note: Coordination of Benefits (COB) helps us determine the correct order in which your insurance plans will be billed. If your child is covered under more than one plan, please list both below. Providing accurate insurance information upfront allows us to verify your child's benefits before services begin and avoid any delays or unexpected costs.
  • Primary Insurance*
  • Secondary Insurance*

  • 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:*

  • Additional Information

  • Former client: Is this child a former client of Snowflakes ABA?
  • Gender Requirement for RBT: Do you have a strict gender requirement for the RBT?
  • Form completed by

  • Referral

  • How did you hear about Snowflake ABA?

  • Thank you for your interest in Snowflakes ABA! 

  • Should be Empty: