First Buddies Fall Term 2019 Application
Hello! Thank you in your interest in Infinity ABA Therapy & Autism Service's social skills program for early learners! This is our first step of our process in getting started with our Social Skills program! This form will help us determine if your child is a right fit for our program at this time. After receipt and review of this application, our team will contact you to discuss your family's needs and the next steps of the process. Thank you!
Email address *
Child's Full Name *
Your answer
Nickname
Your answer
Child's Age *
Your answer
Child's Gender *
Child's Date of Birth *
Your answer
Parent's Name *
Your answer
Parent's Phone Number *
Your answer
Does your child have diagnosis? If so, please include
Your answer
Communication *
Independence *
Toileting *
Challenging Behaviors *
If your child is currently in school, select placement type *
Identify the top 3 skills you would like to address in this social group. *
Your answer
Child's interests include *
Your answer
Child's dislikes include *
Your answer
Parents are required to attend Parent's Circle (session for parents that runs simultaneously with First Buddies). Are you able to participate in these sessions? *
Who will be attending the Parent's Circle? *
Limit to 2 people. Include name and relationship (ex. Mother - myself, Caregiver - Luke Skywalker)
Your answer
What do you hope to get out of the Parent's Circle? *
Your answer
Do you have any additional questions you would like us to address?
Your answer
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