Family Resource and Clinic Day
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Email *
Phone Number *
Parent/Caregiver Name (First/Last) *
Phone Number *
Child Name (First/Last) *
Child's Date of Birth *
MM
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DD
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YYYY
OAP Reference Number *
Does your child have a diagnosis other than ASD? If yes, please list other diagnoses. *
Has your child received ABA services in the past? If yes, did you receive services from us at Community Living North Halton? *
I understand that I am signing up for a Family Resource and Clinic Day, where I will have up to a 1 hour appointment with a Behaviour Clinician to discuss ideas and general strategies on target behaviours. *
Please provide a brief explanation on the target behaviour you would like to discuss during your appointment. *
A copy of your responses will be emailed to the address you provided.
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