Spring/Summer ABA Group Intake Form

Spring/Summer ABA Group Intake Form

Core Clinical Autism Services - 2-hour time blocks (9 am - 11 am/11:30 am - 1:30 pm/ 2pm - 4pm)
I am a... [Client requesting services/Parent or caregiver/ Medical Professional or Community Agency] *
Date of Birth of the individual being referred*

MonthDayYear
Date
What time of Spring/Summer ABA Group are you requesting? What is the 2-hour time block desired and the number of weeks.*

9 am - 11 am1:30 am - 1:30 pm2 pm - 4 pmFriendship Group - Ages 2-5 (6 weeks / 10 weeks / 12 weeks)Friendship Group - Ages 6-9 (6 weeks / 10 weeks / 12 weeks)Friendship Group - Ages 10-13 (6 weeks / 10 weeks / 12 weeks)Friendship Group - Ages 14-18 (6 weeks / 10 weeks / 12 weeks)Conversation Crew - Ages 2-5 (6 weeks / 10 weeks / 12 weeks)Conversation Crew - Ages 6-9 (6 weeks / 10 weeks / 12 weeks)Conversation Crew - Ages 10-13 (6 weeks / 10 weeks / 12 weeks)Conversation Crew - Ages 14-18 (6 weeks / 10 weeks / 12 weeks)Story Time - Ages 2-5 (6 weeks / 10 weeks / 12 weeks)Story Time - Ages 6-9 (6 weeks / 10 weeks / 12 weeks)Story Time - Ages 10-13 (6 weeks / 10 weeks / 12 weeks)Story Time - Ages 14-18 (6 weeks / 10 weeks / 12 weeks)
Parent or Caregiver Information / Medical Professional Information/Community Agency and Contact Information
Name*

First NameLast Name
Main Phone*
Phone Number
Email*
example@example.com

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*Your signature below indicates that the information you have provided above is truthful and demonstrates a committment to accessing services with Equanimity Behaviour Analyst Inc.

*Pre-requisite Skills (varies across groups): Shows interest in peers; Can join group activities for up to 20 minutes; Enjoy sharing their interest; These programs may not be suitable if your child; Does not yet speak in full sentencesShows little interest in socializing; Displays behaviours that could cause injury or require emergency help.

*Your signature below indicates that you confirm that your child meets the criteria to participate in Equanimity Behaviour Analyst Inc.'s Spring/Summer programming.
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Parent or Caregiver Information / Medical Professional Information/Community Agency and Contact Information