Application for Services

Application for Services
Parent/Guardian Information
Parent/Guardian 1 Name: *

First Name Last Name
Primary Phone: *

Area Code Phone Number
Email: *
example@example.com

Address: *

Street Address
Street Address Line 2
City	Province
Postal Code	Country

Parent/Guardian 2 Name:

First Name Last Name
Primary Phone:

Area Code Phone Number
Email:
example@example.com

Address (if different from above):

Street Address
Street Address Line 2
City	Province
Postal / Zip Code	Country

Child Information
Name: *

First Name Last Name
Age: *
Date of Birth: *

Month Day Year
Gender *

Primary Address (if different from above):

Street Address
Street Address Line 2
City	Province
Postal Code	Country

Autism Diagnosis: *

Yes No Waiting List
Allergies/Dietary Restrictions:
Medical and/or Mental Health Conditions:
Daycare/Preschool/Distributed Learning School/School:
Grade:
Has your child received ABA services in the past? *

Yes No
If yes, where?
Current Therapists and Professional Services:

Rank each behaviour excess to decrease by the extent to which it does or does not interfere with daily life: *

Never Occurs

Sometimes Occurs

Always Occurs

Physical Aggression

Self-injurious Behaviours

Property Destruction

Sensory Challenges

Self-stimulatory Behaviours

Noncompliance

Feeding Challenges

Sleeping Difficulties

Rank each behaviour deficit to increase by the extent to which it affects your child's ability to acquire new skills or make meaningful relationships: *

Poor

Good

Excellent

Not Applicable

Academics

Communication

Motor Skills

Social Skills

Daily Living Skills

What are your priorities for therapy? *
Additional information you'd like us to know about your child (e.g., triggers, fears, dislikes, interests, etc.): *
Services
Desired Services: *

1:1 Behaviour Intervention (0-18 years): Weekdays 8:30am - 3:30pm Social Skills Group (Grades K-6): Weekdays 3:30pm - 5:00pm Teen Group (Grades 7-12): Tuesdays 3:30pm - 5:00pm School, Home, and/or Community Consultation
Desired Start Date: *

Month Day Year
Business Hours: Monday to Friday 8:30am to 5:30pm with a total of five weeks of closure spread out over the course of the year (two weeks at Christmas, two weeks at Spring Break, and the first week of September). Families may also receive two weeks of non-billable vacation scheduled with minimum four weeks notice. No sessions on statutory holidays as outlined by the BC Labour Standards.

Cost: We will work with you to develop a program that fits your budget.
Note: Completion of this form does not guarantee a seat in our programs. Once your application is reviewed we will contact you to confirm your eligibility. If you wish to arrange a tour or have questions, please contact info@gatewaybehaviour.com or (250) 645-0996.
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Application for Services

Parent/Guardian Information

Child Information

Services