Reliable Engaging AAC Trainings
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Participating Caregiver's Name *
Email *
Phone Number (Cell preferred for text messaging) *
Mailing Address *
Child Participant's Name *
Child Participant's age *
Relationship (to the child participant) *
Has your child be diagnosed with Autism? *
If no, please list any relevant speech & language diagnosis. *
Does the child participant currently have access to a robust speech generating device (e.g., iPad with Proloquo2Go or Accent) *
Please briefly describe how the child participant currently communicates his/her wants & needs.
Have any of the following communication strategies been successful for your child? *
Required
Does your child currently receive private speech-language therapy? *
Please briefly describe any financial, therapeutic, and emotional needs driving your participation in this program. *
Please describe what you hope to learn from participating in this program. *
Household Income *
Is there anything else you think we should know? *
As a part of this program I will be participating in video tapped sessions including but not limited to video-tapped therapy session, still photos, and/or parent testimonials. BIANCA will have the right to use these videos, photographs, and other non-identifying information (e.g. for education, promotion, etc.) for this and future projects. *
Required
If you do NOT agree to the above stipulation. Please describe what you are comfortable participating in.
Signed *
Date *
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