Bridge Kids NY ABA Therapy Request Form

ABA Therapy Request Form

BridgeKidsNY
Child's Name*

First NameLast Name
Child's Birth Date:*

MonthDayYear
Home Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Child's School Name*
School Name
School Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Type of Educational Setting*
Please select the setting that most closely describes your child's current educational setting.
Child's Grade
Grade
Classroom Size
Student: Teacher: Para (Ex. 8:1:1, 25:1:1)
Guardian #1 Name*

First NameLast Name
Guardian #1 Cell Phone Number:*
Format: (000) 000-0000.
Guardian #1 E-mail*
example@example.com
Guardian #2 Name

First NameLast Name
Guardian #2 Cell Phone Number:
Format: (000) 000-0000.
Guardian #2 E-mail
example@example.com
Does your child have any diagnoses or IEP classifications*
Please select all of your child's current medical diagnoses:*

Other
Does your child currently receive ABA therapy?*
If yes, my child currently receivesnumber of hours per week* hours of ABA therapy per week provided by the following agency: name of ABA agency or provider*
Does your child currently receive any related services?*
If you selected Yes above, Please name all related services that your child is currently receiving both at school and/or home/center. Please include the frequency of each service (number of sessions per week x length of session in minutes)*
What are your general concerns regarding your child?*
How do you see ABA therapy benefitting your child?*
Our ABA services are intense and comprehensive. As a result, our minimum ABA therapy requirement is 8 hours per week across at least 4 days. How many hours are you interested in your child receiving per week?*
Where are you interested in your child receiving ABA services?*

Other
What is your family's availability for ABA therapy? *
Please select an option below indicating you are aware that we are a private practice and we do not accept insurance or medicaid. *
If you are working with an education attorney, please include the first and last name of your attorney*

First NameLast Name
*
Law Firm
If your child has been awarded ABA therapy as the result of an impartial hearing order, please attach your hearing order here for us to review

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If your child has been prescribed ABA therapy by a medical professional, please attach the written documentation here for us to review

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Please attach your child's latest IEP for our review

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Should be Empty: