Group Parent Training Inquiry
Child's Name
First Name
Last Name
Child's date of birth
-
Month
-
Day
Year
Date
Level of ASD Diagnosis
Please Select
Level 1
Level 2
Level 3
Does your child have any other diagnoses? If so, please list
Parent Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Are you currently enrolled in ABA services?
yes
no
on a waitlist
if you put YES, you would not be able to be approved for these to be covered by insurance. Our self pay rate is 150 per hour. Is this something you could accommodate?
yes
no
would need payment plan
what time would work best for you?
morning
afternoon
after school (3-5)
All of the above
These would occur without the child present for ONE HOUR AT A TIME(there will be opportunities to bring your child as well but this will be planned) is this something you could accommodate?
yes
no
How often would you like to attend these group sessions?
weekly
bi weekly
monthly
You would be required to do an initial appointment and assessments for your child, is this something you would be able to do?
yes
no
We ask that you commit to at MINIMUM 6 months to 1 year of services based off of what your insurance approves. Is this a commitment you can make?
yes
no
Please select your preference of how you receive services:
in person
Telehealth
no preference
mixed
Tell me your top 3 goals that you as a parent would like to accomplish.
Submit
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