Summit Autism Center Information Request
Guardian Name:
*
First Name
Last Name
Email
*
example@example.com
Phone Number
-
Area Code
Phone Number
Child's Name:
*
First Name
Last Name
Child's Age:
*
Does your child have a diagnosis of Autism?
*
Yes
No
Date of diagnosis?
-
Month
-
Day
Year
Date
Program Options
Full Day (7-8 hours a day)
School Day (6-7 hours a day)
Preschool / 1:1 Therapy (5-6 hours a day)
Afterschool (2-4 PM)
Do you have insurance that covers ABA?
Yes
No
Insurance provider?
Has your child received ABA therapy before?
Yes
No
What current services does your child receive?
(public school, private school, ABA program full time, day care, none)
How did you hear about us?
Please Select
Doctor
Social media
Internet search
Friend/relative
Referral from Speech, OT, PT
Other
Check the box below
*
Submit
Should be Empty: