ABA & Remediation Services

Application Form – ABA & Remediation Services (Ages 0–17)

Please complete this application form. It helps us understand your child’s needs and determine appropriate services.

1. Child Information

Child’s Full Name

Date of Birth

Age

School / Preschool (if applicable)

Grade / Class

2. Parent / Guardian Information

Parent / Guardian Full Name

Relationship to Child

Phone Number

Email Address

Home Address

3. Services Requested (check all that apply)

ABA ServicesAcademic Remediation / Learning SupportParent / Caregiver Coaching

4. Primary Concerns

Briefly describe your child’s main challenges (behavior, learning, communication, social skills, etc.)

5. Goals for Your Child

What skills or changes would you like to see as a result of services?

6. Consent for Home and School-Based Services

I give permission for my child to receive ABA and/or remediation services in the following settings, as appropriate: home, school, or community environments. I understand that collaboration with teachers and caregivers may occur to support my child’s progress.

I understand that services will be provided in a respectful, child-centered manner and that I may withdraw consent at any time by providing written notice.

[acceptance* service-consent] I agree and provide consent

7. Parent / Guardian Acknowledgement

Parent / Guardian Full Name

Signature (type full name)

Date

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