Bridge Kids NY ABA Therapy Request Form

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:

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?

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

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

Please attach your child's latest IEP for our review