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Request for In-Home ABA Services
Kindly provide the following information, in it’s entirety, so that we can quickly work to secure appropriate in-home providers.
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* Indicates required question
Email
*
Your email
Date of this request:
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MM
/
DD
/
YYYY
Requested start date of the service (minimum two week lead time required):
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MM
/
DD
/
YYYY
Sending School District:
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Your answer
Sending School District Contact Person for this service:
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Your answer
Contact person Phone #:
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Your answer
Contact person Email Address:
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Your answer
Name of Child/Youth receiving in-home services
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Your answer
Age and Grade Level of Child / Youth receiving in-home services
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Your answer
Name of Parent/Guardian:
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Your answer
Parent/Guardian Phone #:
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Your answer
Parent/Guardian EMAIL Address:
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Your answer
Physical Address where services will be provided:
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Your answer
What school program does the student attend?
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An SBJC Campus
An out of district placement other than SBJC
An in-district special education classroom
An in-district general education classroom
Home Instruction
Other:
Reason for referral for services. Please list the types of goals that should be targeted during the services. (e.g., behavior, functional life skills, generalization of learned skills, academic instruction, community based instruction)
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Your answer
Please select the type of service needed:
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IN-HOME ABA THERAPY (Direct ABA-based instruction is provided to the student via an ABA trained therapist. Programming is set up and monitored by a Program Coordinator). Amount of Coordination hours are based upon criteria in the SBJC Home Program Manual and are billed separately.
FAMILY HOME CONSULTATION / PARENT EDUCATION (An ABA provider works directly with the parent/guardian to educate them on the application of the principles of ABA to address behavior challenges in the home/community. Behavior is functionally assessed and interventions are developed. The provider supports the parent in directly addressing/modifying the behaviors)
# of hours per week
Your answer
# of hours per month
Your answer
Total # of hours requested
Your answer
This service will be provided (please select all that apply):
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During regularly scheduled school days only
Uninterrupted (regular school days and during school breaks)
During Extended School Year (ESY)
During August
Required
Administrative Approval
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By checking this box, I signify that the service has been approved by our Board Secretary or designee and will be paid for by our Local Sending District
Required
Name of Board Secretary or Designee who has provided approval:
*
Your answer
A copy of your responses will be emailed to the address you provided.
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