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*

FemaleMale
Child's Date of Birth*

MonthDayYear
Primary Language Spoken in the Home*
Does your child have a current diagnosis of autism?*

YesNo
If yes, at what level?*

Level 1Level 2Level 3N/A
If you answered yes to the above, which type of doctor?*

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

AD/HDDown SyndromeGlobal Developmental Delay/Significant Developmental DelayIntellectual DisabilityLanguage DisorderNoneOther
What is your child's level of communication?*

Completely nonverbal with no functional communication used to get needs and wants metNonverbal, but uses pictures (e.g. PECS), electronic form of communication (AAC), or sign language to communication wants and needsCommunicates vocally with 1- to 2-word phrasesCommunicates vocally with 3- to 5-word phrasesCompletely verbal; communicates wants and needs in full functional sentences
What are your child's toilet training needs?*

Not toilet-trained; currently wearing diapers.Successfully goes to the bathroom at least once per hour with assistance if verbally reminded; if not accidents occur.Successfully goes to the bathroom at least once per 3 hours with assistance if verbally reminded; if not accidents occur.Can independently complete all tasks surrounding going to the bathroom, but lacks the skill to vocalize the need to use the restroom.Is completely toilet trained, can identify when they need to “go”, will notify an adult/caregiver of this and will use the toilet independently without assistance.
How will you pay for therapy?*

I have Aetna insuranceI have Amerigroup insuranceI have Anthem Blue Cross Blue Shield/EvernorthI have CareSource insuranceI have Cigna insuranceI have Magellan insuranceI have Peach State Health insuranceI have Optum/United Behavioral Health insuranceI have TricareI have straight MedicaidI am a private pay clientI will be using out-of-network benefitsOther
Does your child currently attend school?*

Yes, in a public school program.Yes, in a private daycare/preschool program.No, my child is not currently enrolled in any school program.No, my child is being home-schooled.
Are you available for daytime trainings and meetings?*

Yes, all the timeYes, sometimesNo, not at all
Are you willing to participate in group sessions with other parents/guardians?

YesNo
How many hour of therapy do you feel your child needs per week?*

6 to 9 hours per week10 to 15 hours per week16 to 20 hours per week21 to 30 hours per weekOver 30 hours 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?*

FaeebookInternet searchPersonal ReferralPhysician ReferralPsychology TodayOther
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