Elevation Behavioral Autism Therapy Services Interest Form
Thank you for your interested in life changing, child-centered Autism Therapy Services from Elevation Behavioral.  Please take a few minutes to complete this form.  Once we have received the completed form, we will review your information and contact you to discuss service options.  We look forward to talking with you!!
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Client's Full Name *
Client's Preferred Name *
Client's Date of Birth *
MM
/
DD
/
YYYY
Your Name *
Your Relationship to the Client *
Are you the Legal Guardian of the Client? *
Your Phone number *
Your Email Address *
Street Address
City *
State *
Zip Code
How will services be paid for? *
Required
Who do you have health insurance through?
*
If the client has Secondary Insurance carrier, please provide the insurance carrier name.
Does the client have an Autism diagnosis? *
Do you have a hard copy of the Autism diagnosis from the diagnosing physician? *
Please list any other diagnoses the client has.
Select the primary method of communication for the client. *
What are your main concerns or areas that you feel the client needs help with? *
What programs are you interested in for Autism Therapy?   Check all that apply. *
Required
Does the client attend school? *
If yes, what grade, placement, and if not full day, what is their schedule?  (if no - N/A) *
Does the client have an IEP, 504, or BIP?  Check all that apply.
Indicate any other services the client currently receives.   Check all that apply. *
Required
Which days would the client be available for services?  Check all that apply.  (A minimum of 6 hours of services per week are required - actual hours needed for effective therapy will be determined during assessment) *
Required
What times during those days would the client generally be available for services?  Check all that apply. *
Required
Parent participation is essential to the the success of ABA therapy services.  Are you willing to participate in the services and implement the treatment plans that our BCBA's create? *
How did you hear about Elevation Behavioral?
Anything else you would like to share with us regarding your child?
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