Client Inquiry Form

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Client Inquiry Form

At Dogwood Autism Services, our team specializes in early intensive behavior intervention ABA therapy (30+ hours per week) for children aged 1-6 diagnosed with Autism Spectrum Disorder.

Please complete the form below to join our client interest list and to receive more information about ABA Therapy for your child.

We will email you and connect you with a clinician within 2 business hours!

Caregiver first name *

Caregiver last name *

Email *

Phone *

Full Address *

This allows us to ensure we route you to the closest clinic location.

Which primary clinic location are you considering for services? *

See your projected drive time to the clinic if you left at 730am:

Douglasville, East Point, Lithonia, Newnan, Roswell, Sandy Springs, Woodstock

What is the best way to get in contact with you? *

Our main method of communication and fastest way to get in touch with us is via email.

Phone

What is your child's name? *

What is your child's date of birth? *

Our team specializes in early intensive behavior intervention ABA therapy for children aged 1-6 diagnosed with Autism Spectrum Disorder.

YYYY

How old (years) is your child? *

Our team specializes in early intensive behavior intervention ABA therapy for children ages 1-6.

What is your child's gender? *

Male

Female

Has your child been diagnosed with Autism Spectrum Disorder in the past 3 years? *

If no, we may still be able to support your child. We will send referral sources for diagnosing pediatricians and psychologists who are experienced with ASD.

Yes

Yes, but we're waiting on a report from the doctor

What was the date of their Autism Spectrum Disorder diagnosis? *

Who is your primary insurance provider? *

Who is your secondary insurance provider? *

Are you actively pursuing the Katie Beckett waiver for your child? *

The Katie Beckett Deeming Waiver is a form of Medicaid intend to help families cover the out-of-pocket costs associated with ABA therapy beyond what their private insurance will cover.

Yes - I have already been approved for the Katie Beckett waiver

Yes - My application has been submitted

Yes - I'm planning to apply for it and understand I have to notify Dogwood Autism Services immediately after my application is submitted

No - I'm not planning to apply for it and understand I have to notify Dogwood Autism Services immediately if I decide to pursue it.

No - But I want more information and understand I have to notify Dogwood Autism Services immediately if I decide to pursue it.

Has your child ever received Applied Behavior Analysis (ABA) services before? *

Yes - weekly direct ABA therapy

Yes - caregiver training only (we never started direct therapy)

Yes - only completed an in-person ABA assessment (we never received any direct therapy or caregiver training)

I'm unsure

Are you willing/able to commit to 30 hours or more of direct therapy each week if clinically recommended by our Behavior Analysts? *

Research suggests (see pg 36-37 for visuals), that an early intensive & comprehensive ABA therapy model is the most effective way to achieve the desired goals for children ages 1-5. As such, we require that caregivers commit to the clinical recommendations of our Behavior Analysts to ensure your child's unique needs are met.

Yes

I am unsure. I would like further explanation on this commitment.

How did you hear about us?

Additional information

Please share any additional information you believe will be beneficial for assessment.

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