Initial Contact Form First and last name Child's name Child's Age Email Phone (###) ### #### Address How did you find out about us? A friend or family member Our website Social Media Google search Pediatrician or therapist referral Preferred Center Location Frisco Wylie Murphy First Available: Wylie or Murphy Preferred Hours of Therapy Unsure Flexible Full-Time Part-Time Group Hours How Many Hours of Therapy are you Interested in Per Week? Under 10 11-20 21-30 31-40 Does Your Child Have a Current Autism Diagnosis by a Doctor (within the last 3-5 years) Yes No In Progress If Yes, Please Provide the Name of the Doctor and the date the Diagnosis was received: Has your Child Received ABA Therapy in the Past? Yes No Currently receiving Services Does Your Child Attend School or Other Therapies School Occupational Therapy Speech Therapy Physical Therapy None If Your Child is in School, What Type of Classroom are They in? General Education (No supports) Inclusion in General Education Classroom Resource Classroom Self-Contained Classroom My Child is Insured by the Following Insurance Companies Aetna BCBS/Anthem United Healthcare Tricare Cigna Magellan ChampVA UMR Medicaid Oscar No Insurance-private pay is an option Other Any Other Comments Thank you!
