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Autism
Ottawa ABA Academy
Child's Full name
*
Birthday
*
Year
Month
Day
Parents full name
*
Email
*
Phone number
*
Address
*
Emergency Email
*
Emergency Phone number
*
Does the child have OAP (Ontario Autism Program) funding?
Do you have private insurance coverage for ABA therapy?
Has the child been diagnosed with Autism or any other developmental disorder? (if yes Explain)
Does the child have any allergies?
Does the child require medication during therapy sessions?
Does the child have any sensory sensitivities?
Is the child verbal or non-verbal?
Does the child exhibit any challenging behaviors?
Has the child previously received ABA therapy?
Preferred days for therapy
Preferred times for therapy
Preferred session duration (2 to 7 hours) and Start date preference.
Is the child currently enrolled in school? What is the school name?
Does the child receive any additional support at school (e.g., EA, IEP, resource support)?
Any additional comments or information that may help us provide the best support?
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