CAC Initial Intake Questionnaire
Please complete the following intake questionnaire for our Diagnostic Evaluation and/or Applied Behavior Analysis (ABA) services and a member of our intake team will be in contact with you as soon as possible.

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Child's First and Last Name *
Child's Date of Birth (DoB) *
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DD
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Parent/Caregiver First and Last Name *
Parent/Caregiver Email Address *
Parent/Caregiver Phone Number *
Current Address (Address, City, State, Zip Code) *
Name of Primary Insurance *
Name of Secondary Insurance (if applicable)
What service(s) are you seeking for your child? Please note that we are only able to serve those seeking an  Autism Assessment or Cognitive Assessment (i.e., concerns for Global Developmental Delay or Intellectual Disability). We cannot provide assessments for AD/HD, learning disorders, or memory/mental health problems. *
If you are inquiring about ABA Therapy services, which location are you interested in?
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Does your child have an existing Autism Spectrum Disorder (ASD) diagnosis? *
CAC schedules sessions from 8am-6pm Monday - Friday. For children/families who move forward with ABA Therapy services, we require that the child be available 5-days per week. The actual number of hours will depend on clinical recommendations made during the assessment process. 

If you are seeking ABA Therapy Services, please attest that your child is available to attend consistently 5-days per week.
*
What is your primary language spoken at home?
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How did you hear about Comprehensive Autism Center (CAC)?
If you were referred by your child's doctor or another provider, please indicate their name.
Please share a brief description of why you are seeking services for your child.
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