Applied Behavioral Approaches’ Early Intervention Autism Center Enrollment

Applied Behavioral Approaches' Early Intervention Autism Center Enrollment

Completing this form does not ensure acceptance in the program.
Prefix
Your Name

First NameLast Name
Relationship to the Child
(e.g., mother, father, grandparent, etc.)
Your E-mail
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Name

First NameLast Name
Child's Age
Child's Gender
Child's Date of Birth

MonthDayYear
Primary Language Spoken in the Home
Does your child have a current diagnosis of autism?
If yes, at what level?
If you answered yes to the above, which type of doctor?

Other
Does your child have an additional diagnosis(es) (Check all that apply)

Other
What is your child's level of communication?
What are your child's toilet training needs?
How will you pay for therapy?

Other
Does your child currently attend school?
Are you available for daytime trainings and meetings?
Are you willing to participate in group sessions with other parents/guardians?
How many hour of therapy do you feel your child needs per week?
How soon are you seeking to start ABA therapy?
Insurance
Front of Insurance Card
Back of Insurance Card
Psychological Report with Autism Diagnosis

Browse Files

Cancelof
Prescription/Letter of Medical Necessity for ABA Therapy from Doctor

Browse Files

Cancelof
IEP or IFSP

Browse Files

Cancelof
Other Reports (e.g., speech therapy, occupational therapy, previous ABA therapy, etc.)

Browse Files

Cancelof
How did you hear about us?

Other
In the event that you find another clinic that has ready availability for your child, please contact us to have your child removed from the waiting list.

Thank you!
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Applied Behavioral Approaches' Early Intervention Autism Center Enrollment