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All Texas Families
Please answer the following questions to the best of your ability and click 'Submit' once you are finished.
Please provide your name (First, Last)
Your answer
Are you military affiliated? If yes, what branch
Your answer
What is the name of the individual with autism?
Your answer
What is your relationship to the individual with autism?
Your answer
How old is the individual with autism?
Your answer
Do you currently live in Texas?
What is your permanent address?
Your answer
What is the best phone number to reach you?
Your answer
Is the individual consistently in school or in a school-like setting?
If Yes, please indicate grade level and setting (For example: home-schooling, private school, public school, PPCD, etc.)
Your answer
What services does the individual receive right now? Check all that apply.
Required
How does the individual typically communicate on a daily basis? For example, using complete sentences, manual sign, picture exchange, or a vocal output device. Please explain.
Your answer
Are there any concerns you have regarding his/her communication skills? If yes, please explain.
Your answer
How does the individual typically act in a social or play situation with his/her peers?
Your answer
Are there any other concerns you have regarding his/her overall social skills? If yes, please explain.
Your answer
Does the individual exhibit disruptive, inappropriate or challenging behaviors during daily routines?
If Yes, please list and describe the disruptive, inappropriate, or challenging behaviors.
Your answer
Which daily living skills does the individual complete independently? Check all that apply.
Required
What are your top three concerns for the individual? (Please begin with #1 as top priority.)
Your answer
What is a good email that we may reach you at?
Your answer
Do you have access to internet?
Do you have a way to video yourself working with the individual? (e.g., video camera, webcam, phone camera, tablet camera)
Do you have a way to upload videos to OneDrive? Note: We will provide you with a OneDrive account, but you must have a way to upload videos.
Do you have the technology to video conference with your BCBA-D trainer? (e.g., Skype, FaceTime, VSee)
How did you hear about our program?
Your answer
Thank you for your time and for providing your considerate responses.
If you have any questions, please email us at autismmilitaryparenttraining@gmail.com
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