ABA Registration & Intake

Parent's name

Child's name

Child's D.O.B

Email

Phone

Address Line

Concerns with Child's development and/or behavior

Child's Diagnosis (Please select all that apply):
AutismADHDAnxietyLearning Disability

Other (Display of one or more of the following behaviors /maladaptive)
StereotypesInability to stay organizedSelf-injurious behaviorsInterpersonal relationship dysfunctionAggressionRitualistic BehaviorsImpulsivityOppositional / Defiant BehaviorInattentionProperty DestructionTantrumsPICA/ MouthingHyperactivitySensitive to changeFailure to comply with instruction

Insurance (If known):
MedicaidMedicaid HMOPrivate Pay

Other

Please Specify

Setting (choose one or more)
HomeSchoolCommunity

Availability (choose one or more)
MorningsAfternoonsEvenings

Other

Please Specify

*Kindly submit all documents and or evaluations available.