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:*
Guardian #1 E-mail*
example@example.com
Guardian #2 Name

First NameLast Name
Guardian #2 Cell Phone Number:
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:*

Autism Spectrum Disorder (ASD)Attention-Deficit Hyperactivity Disorder (ADHD)Obsessive-Compulsive Disorder (OCD)AnxietyDepressionOppositional Defiance Disorder (ODD)Post Traumatic Stress Disorder (PTSD)None of the aboveOther
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?*

8-10 hours10-15 hours15-25 hours25-40 hours
Where are you interested in your child receiving ABA services?*

Guardian #1 HomeGuardian #2 HomeSchoolCommunityOther
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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