UTSA TEAM Center Family Interest List
The University of Texas at San Antonio - Teacher Education Autism Model

This form is for families interested in receiving applied behavior analysis services for their child(ren) with autism and other language deficits. We specialize in Functional Communication Training - strengthening language skills to reduce challenging behavior.

Children do not need a formal diagnosis to qualify for services at the TEAM Center; they just need to display deficits in communication. ABA sessions are offered Monday through Thursday, concurrent with the UTSA academic calendar. At the beginning of each semester, a new "class" of students will be selected to participate in the program for the duration of that term (approximately 13 weeks).

Our enrollment varies by semester based on ongoing research, but we *typically* provide Early Intensive Behavioral Intervention (through age 5) during the fall/spring semesters, and provide social skills instruction for school-age individuals (through age 21) during the 10-week summer term.

Child and Family Information
Child's Full Name:
Your answer
Child's Birthdate:
MM
/
DD
/
YYYY
Special Education Category/Medical Diagnosis (If any):
A formal diagnosis is not required for participation in the TEAM Center.
Your answer
Parent(s) / Guardian(s) Full Name:
Your answer
Zipcode
E.g., 78207
Your answer
Phone:
E.g., 210-458-2007
Your answer
Email:
Your answer
Primary language spoken at home:
Your answer
Insurance or Third-Party Biller:
(If any.)
Family Financial Information
Optional: We currently charge a one-time fee of $50 per student per semester. This fee may be adjusted according to federal sliding fee discount pay class and percent poverty guidelines. Additionally, enrollment in our program may be prioritized for families that meet federal poverty guidelines.
Number of persons in family/household:
Your answer
Annual income:
Your answer
Behavioral Deficits and Excesses
How does your child interact with others:
Required
How does your child relate to the environment?
Indiscriminate (Inattentive)
Standard
Overly Selective (Fixates)
Looking
Listening
Smelling
Tasting
Feeling
Please describe any challenging behavior:
Your answer
Is there anything else we should know about your child?
Your answer
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