Paragon Therapeutic Consultation Screening Form
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At Paragon Autism Services, LLC, we are dedicated to providing quality person-centered Applied Behavior Analysis therapy for individuals receiving Virginia Waiver-Based Services or through self-pay options throughout their lifespan. 

Thank you for your interest in our Therapeutic Consultation services. Please complete the screening questions below and a member of our Intake Team will contact you.
Client's Name: *
Date of Birth: *
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DD
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Name of Individual Requesting Services: *
Relationship to the Client: *
Support Coordinator Name:
Support Coordinator Phone Number:
Support Coordinator Email Address:
Name of Community Service Board (CSB):
Name of Individuals Guardian *
Guardian Phone Number
Guardian Email Address
Name of the Primary Contact for Individual: *
Relationship to the Individual: *
Phone Number of Primary Contact: *
Email Address of Primary Contact: *
Contact Preference: *
Where may we leave messages for this contact?   *
Required
Contact Preference
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