New Client Interest Form
If you are interested in getting more information about our services, please complete the following form. A member of our team will reach out to you shortly with more information about enrollment and insurance information. We look forward to working with you!
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Email *
Guardian's Name *
Relationship to Child *
Child's Name *
Child's Date of Birth *
Guardian's Phone Number *
Home Address
Requested Start Date of Services *
Insurance Carrier's Name *
Insurance Member ID *
My child's pediatrician has referred us to services for: *
Please provide the following information: Referring Physician's Name, Practice, and Diagnosis Date if applicable. *
Is your child currently receiving ABA therapy? *
What is your availability? *
Does your child engage in social games? (e.g. tickling, peek-a-boo) *
Can your child sit for at least 2 minutes and focus on an activity? (ex: coloring, watching a video) *
Which best describes your child's communication? *
Can your child independently play for at least 1 minute at a time? *
When given a preferred item (ex: toy, video, food), does your child use or take the item appropriately? *
Please describe your child's needs in a few words. Please include their diagnosis, what services they're currently receiving, areas you would like to work on in ABA therapy, and any other relevant information you think would be helpful for our team to know. *
How did you hear about us? *
Have you spoken to anyone at ACT about our services? *
A copy of your responses will be emailed to the address you provided.
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