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Selah Respite Care Consultation
Name *
Email *
Location : City and State *
Best Contact Number *
How many loved ones will be receiving services *
Name of loved one(s) *
How old is your loved one (s) *
Height and weight of loved one ( for matching purposes ) *
What does your loved one(s) like to do? *
Does your loved one have any behaviors? If yes, please explain (Selah Respite does NOT participate in spectrum discrimination, this information is for matching purposes ) *
Is your loved one in public school or ABA? *
Name of Public School or ABA . ( we try to collaborate with loved ones educational institutions to provide structured homework help and ABA Structure) you may opt-out of this service. This service is included in the 25.00 per hour *
Type of care needed (check all that applies) *
Required
How Soon Do You Want to Start Services *
How Did You Hear about us ? *
Required
By checking this box you allow us to contact you for your consultation and for sales and marketing purposes and understand that placement will not start until the non - refundable 75.00 registration fee is paid *
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