Contact Information & Questionnaire
This form allows us to better meet the needs of your child when we get in contact with you.
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What is your name? *
If applicable, what is your child's name?
What is your child's date of birth? *
If applicable, does your child have an autism diagnosis? *
What service(s) are you seeking from Adaptive Teaching and Learning Autism Services? *
If applicable, who is your insurance provider?
If applicable, has your child received ABA services previously? If so, in what setting(s) and for how long?
If applicable, does your child receive any other services? If yes, please list other services.
What is the best phone number to reach you? *
What is the best email address to reach you? *
Do you prefer call, text, email, or any combination of the three? *
What day(s) of the week and what time(s) are the best to reach you? *
Do you live in any of the following counties? *
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How did you hear about us? *
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