Getting Started - Accelerate ABA

Please provide the following information(required)

My child is between ages 2-5 and I am interested in 1:1 teaching and developmental play group services

Parent/Guardian Name(s)

Location

Child Name

Child date of birth (MM/DD/YYYY)

Child gender(required)

Male

Female

Has your child been diagnosed with autism spectrum disorder? This is a requirement for ABA services in New York State.(required)

Yes

Please list any additional diagnoses your child has

Who is your child's insurance provider?

What is your child's insurance ID number?

What is the provider contact phone number listed on the back of the insurance ID card?

What skills are you hoping to address with ABA services? (Check all that apply)

Language & Communication

Social Interactions

Play skills

Self-help & independence (feeding, toileting, dressing)

Attending & focus

Other

Has your child ever participated in ABA services?(required)

Yes - currently

Yes - in the past

Never

Current/Former provider name and agency, if applicable

Does your child currently attend a preschool or daycare program?(required)

Yes

Name of preschool or daycare program, if applicable

Parent/Guardian Phone Number

Parent/ Guardian Email Address

I understand that Accelerate ABA only provides center-based services and my child will need to be picked up/dropped off for services.

How did you hear about us?

Physician referral

Name of Physician:

Facebook

Instagram

Internet Search

Other professional/agency

Name of other professional/agency:

Current client

Other: