Spec Results Application

Spec Results Application
Which Spec Results option are you intersted in?
Learner's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
What is the name of your child's health insurance provider (e.g. Buckeye Health Plan)?
Age
Place of Birth
Gender

MaleFemale
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Grade Level
School Year
School Last Attended
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian's Information
Parent/Guardian's Name - Primary

First NameLast Name
Occupation
Phone Number
Please enter a valid phone number.
Parent/Guardian's Name - Secondary

First NameLast Name
Occupation
Phone Number
Please enter a valid phone number.
In case of emergency, who will be notified? Please answer the fields below:
Emergency Contact Person

First NameLast Name
Emergency Phone Number
Please enter a valid phone number.
File Upload

Please upload a copy of your child's most recent evaluation that reflects a diagnosis of autism. All forms are protected by federal HIPAA guidelines. If you do not have a copy please fax to (419)458-2440.
File Upload

Cancelof
Learner History
What type of support would you like for your child to have to be successful? This can be in any area. E.g. 'Johny has a hard time following directions or answering math questions.'
Does your child have any known allergies or medical conditions, please list them down below:
Does the learner currently take any medications? If yes, please list them down below:
What interests you in Spec Results as an ABA therapy option for your child?
Reminders
Intake Process

1. Spec Results will request a copy of your child's autism evaluation/diagnosis from a qualified mental health professional. If you can not upload this document, you can request to have it faxed to the following number: (419)458-2440

2. Once documents have been recieved, we will then schedule a time for an in-person evaluation. This evaluation can take place in-clinic or in home. Evaluations take up to an hour on average.

3. Once your child's full evaluation process is complete, we will then create a schedule for your child to start ABA therapy. Therapy can take place in-home (statewide) or in-clinic (Northwest Ohio).

If you have any quetions about the intake process, please contact our office administrator at the email/number below.

info@specresults.net

(419)359-2244
Date Signed

MonthDayYear
Date
Parent/Guardian Signature

Powered by Jotform SignClear
Should be Empty:

Spec Results Application

Parent/Guardian's Information

File Upload

Learner History

Reminders