New Client Information Form

Updated: 9/21/21
WE HAVE IMMEDIATE OPENINGS FOR SERVICES DURING THE MORNING HOURS BOTH IN-HOME & IN-CLINIC.

WE MAY HAVE A VERY SHORT WAIT FOR THERAPY STARTING AT 1PM.

IF YOU WOULD LIKE IN-HOME SERVICES AFTER-SCHOOL HOURS, WE DO HAVE A WAITING LIST.

Please complete the following form if you would like to begin services or be added to our waiting list. We will contact you as soon as we have an opening that aligns with your child's availability. If you are seeking in-home services during after school hours, we encourage you to contact multiple providers in case they may be able to begin treatment sooner.

Email *

I would like to receive emails from Trusty Behavioral Services including newsletters and useful information. I understand my email will not be shared with any third-parties.

Service Location Preference: *

In Home Therapy

At our Clinic (5130 Peachtree Blvd, Chamblee, GA 30341)

Required

Before completing this form, please CAREFULLY read the following statement and acknowledge if you are in agreement. *

I understand that Trusty Behavioral Services provides Applied Behavior Analysis (ABA) therapy both in-home (across metro Atlanta) and in-clinic (at 5130 Peachtree Blvd, Chamblee, GA 30341). Sometimes we are also able to deliver services in your child's daycare (if permitted), and/or in other community settings if treatment dictates. We schedule therapy sessions Monday through Friday between 8:30am-6:00pm. Therapy is NOT provided on the weekends or after 6pm on weekdays. After completion of a comprehensive assessment, a treatment plan is developed that includes a recommended amount of treatment that generally ranges from 10 to 30 hours of therapy per week (typically 3-5 days/week). Patients must minimally meet at least 80% of the recommended weekly treatment hours to remain in the program. If all of the details above are agreeable, please mark acknowledge and continue. If the location, time, or amount of treatment don't work for you then unfortunately we will not be able to help.

I acknowledge

Please select ALL times that your child could be available to receive therapy. Keep in mind the average child needs between 3-5 days and 10-30 hours per week.

9:00am-12:00pm

1:00pm-3:00pm

1:00pm-5:00pm

3:30pm-6:00pm

4:00pm-6:00pm

Monday

Tuesday

Wednesday

Thursday

Friday

Are there any additional considerations we need to know when scheduling therapy?

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