ABA Therapy Eligibility Screening

ABA Therapy Eligibility Screening
Please complete this form to help us determine eligibility for ABA therapy services.
Child's Full Name
First NameLast Name
Child's Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Full Name
First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Home Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Has the child received a formal diagnosis?
If yes, please specify the diagnosis (e.g., Autism Spectrum Disorder, ADHD, etc.)

Current Behavioral and Developmental Concerns

Which therapies or interventions has the child previously received? (Select all that apply)
Other
Describe the child's communication abilities (e.g., verbal, nonverbal, uses sign language, communication device, etc.)
What are the primary goals or concerns you hope ABA therapy will address?
Parent/Guardian Signature
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