If you are seeking applied behavior analysis (ABA) services via your health insurance provider, please submit the following information.
(The information below is not required for families seeking early childhood education (ECE) 1:1 nanny support, however, your signature(s) below are required)
Please describe any medical conditions that the child has been diagnosed with.
Please list all known allergies.
Enter the name of your child's daycare, preschool and/or school. If your child is not enrolled in school or a daycare setting please enter N/A in the field above.
Upload the most recent copy of your child's individualized education plan (IEP). If your child does not have and IEP, please skip this section.
Upload the most recent copy of your child's speech and language pathology (SLP) progress report. If your child does not receive SLP services, please skip this section.
Upload the most recent copy of your child's occupational therapy (OT) progress report. If your child does not receive OT services, please skip this section.
By signing I acknowledge that although intake information has been submitted this does not mean that services will begin immediately. I understand that I must be contacted by a provider who will continue the intake process and assessment process. I acknowledge that if an initial assessment is required, once it is complete a request for approval will be submitted to the health insurance companies. I acknowledge that time for approval and assigning of staff may vary. I
I acknowledge that once I submit forms to begin the intake process and initiate services I am responsible for contacting the intake department to inform them of if I would like to end the intake and/or initial assessment process.
