Getting Started2 - Accelerate ABA

Select one of the following(required)

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

My child is between ages 5-12 and I am interested in social skills group services.

Parent/Guardian Name(s)

Child Name

Child date of birth (xx/xx/xxxx)

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? Please note, we do not accept Medicaid plans at this time.

What is your child's insurance ID number?

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

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: