Application for Services

1
Parent 1 Name* This field is required.
First
Last
2
Parent 1 Telephone Number* This field is required.
Area Code
Phone Number
3
Parent 1 Email* This field is required.
example@example.com
4
Parent 2 Name
First
Last
5
Parent 2 Preferred Telephone Number
Area Code
Phone Number
6
Parent 2 Email
example@example.com
7
Do you have another child already receiving our services?* This field is required.
Yes
No
8
If yes, who?
9
Child Name* This field is required.
First
Last
10
Date of Birth* This field is required.
Month
Day
Year
11
Address* This field is required.
Street Address
Street Address Line 2
City
Province
Postal Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
Gender Identification* This field is required.
13
School* This field is required.
14
Grade* This field is required.
Not Applicable
Daycare
Preschool
Kindergarten
1
2
3
4
5
6
7
8
9
10
11
12
15
Does your child have an autism diagnosis?* This field is required.
Yes
No
Waiting List
16
Does your child have any medical conditions?* This field is required.
Yes
No
17
If yes, please describe.
18
Is your child currently receiving ABA services?* This field is required.
Yes
No
19
If yes, where?
20
Current Therapists and Professional Services:
21
Is your child independent in toileting?* This field is required.
Yes
No
22
If no, please describe the required level of assistance.
23
Is your child independent in mobility?* This field is required.
Yes
No
24
If no, please describe the required level of assistance.
25
What is your child's main form of communication?* This field is required.(check all that apply)
Gestures
Pictures
American Sign Language (ASL)
Speech-generating Device (e.g., TouchChat, Proloquo2Go)
Spoken words
26
Rank each behaviour excess by the extent to which it interferes with your child's daily life
Never Occurs
Sometimes Occurs
Always Occurs
Physical Aggression
Self-injurious Behaviours
Property Destruction
Noncompliance
Wandering & Elopement
Sensory Challenges
Self-stimulatory Behaviours
Feeding Challenges
Sleeping Difficulties
Physical Aggression
Self-injurious Behaviours
Property Destruction
Noncompliance
Wandering & Elopement
Sensory Challenges
Self-stimulatory Behaviours
Feeding Challenges
Sleeping Difficulties
Never Occurs
Sometimes Occurs
Always Occurs
Never Occurs
Sometimes Occurs
Always Occurs
Never Occurs
Sometimes Occurs
Always Occurs
Never Occurs
Sometimes Occurs
Always Occurs
Never Occurs
Sometimes Occurs
Always Occurs
Never Occurs
Sometimes Occurs
Always Occurs
Never Occurs
Sometimes Occurs
Always Occurs
Never Occurs
Sometimes Occurs
Always Occurs
Never Occurs
Sometimes Occurs
Always Occurs
1 of 9
27
Rank each behaviour deficit by the extent to which it affects your child's ability to acquire new skills or form relationships
Poor
Good
Excellent
Not Applicable
Academics
Communication
Fine Motor Skills
Gross Motor Skills
Social Skills
Daily Living Skills
Academics
Communication
Fine Motor Skills
Gross Motor Skills
Social Skills
Daily Living Skills
Poor
Good
Excellent
Not Applicable
Poor
Good
Excellent
Not Applicable
Poor
Good
Excellent
Not Applicable
Poor
Good
Excellent
Not Applicable
Poor
Good
Excellent
Not Applicable
Poor
Good
Excellent
Not Applicable
1 of 6
28
Please describe your reasons for seeking ABA therapy.* This field is required.
29
Desired Services* This field is required.(check all that apply)
Behaviour Intervention (0-18 years)
Social Skills Group (Grades K-12)
Learning Centre (Grades K-12)
Behaviour Consultation
30
Desired Start Date* This field is required.
Month
Day
Year
31
Please note: Completion of this application does not guarantee a seat in our programs. We currently have a waitlist for many of our services and cannot select clients on a first come, first serve basis for many reasons such as staff availability, room availability, sibling priority, and compatibility.
32
Tags
Todo
In Progress
Done
Should be Empty: