Client Inquiry Form
At Dogwood Autism Services, our team specializes in early intensive behavior intervention ABA therapy (25+ hours per week) for children aged 1-5 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!
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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: 
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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.
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 1-5 diagnosed with Autism Spectrum Disorder.
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How old (years) is your child? *
Our team specializes in early intensive behavior intervention ABA therapy for children ages 1-5.
What is your child's gender? *
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.
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.
Has your child ever received Applied Behavior Analysis (ABA) services before?  *
Are you willing/able to commit to 25 hours or more of direct therapy each week if clinically recommended by our Behavior Analysts? *
Our experience is, and research suggests, that a 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.
How did you hear about us?
Additional information
Please share any additional information you believe will be beneficial for assessment.
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