ABA Therapy Interest Questionnaire
Thank you for your interest in Into the Spectrum! We pride ourselves on providing outstanding individualized instruction. We tailor each program to meet your child's specific needs.  

The following is a required pre-intake form to express interest in the ABA Therapy that we provide. This survey is to provide us with the necessary information so that we may determine if your child is an appropriate fit for Into the Spectrum at this time. 

Our on staff Autism Advocate RN will reach out to you soon after you submit this form!

Thank you so much!

(****All of your information that you type on this form is kept SECURE and PRIVATE. It WILL NOT BE SHARED with anyone outside of our organization.****)

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Email *
Child's Name *
Child's Age *
Child's Date of Birth *
Parent/Guardian Name *
Your Home Address *
Phone Number *
Was your child already diagnosed with autism? If so, when were they diagnosed? *
Who was your child diagnosed by? (Doctor's name) *
ABA Therapy Funding Source *
What school or aftercare program does your child attend? *
Does your child require 1:1 support at school? *
Required
Does your child's school allow an outside 1:1 aide? *
Required
How does your child communicate *
Describe your child's ability to follow directions *
Does your child engage in aggression, self injury or property destruction? (within the last 6 months)   *
When is your child available to participate in ABA therapy? (days of the week/times) *
Does your child engage in stereotypy or repetitive behaviors? Please provide examples *
What other services does your child currently receive? *
Required
What does your child love to play? *
How did you hear about us? *
Any other information that you would like us to know
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