The Lighthouse Center for Autism Inquiry
Thank you for inquiring about The Lighthouse! Our Inquiry form allows us to gather information to better assist you and is the first step to be added to our waitlist. If would like to know more about The Lighthouse but do not have a child interested in attending, please see our contact button on our webpage or email admin@jbrlighthouse.com. 
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Parent/Guardian Name *
Today's Date *
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Address *
City *
In which location would you be interested in enrolling your child? *
Phone number *
Email Address *
Child's name *
Child's Date of Birth *
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Does your child have a autism diagnosis by a licensed psychologist? If so, where did your child receive their diagnosis? *
Does your child have any other diagnosis?
Who is your child's PCP and where are they located? *
Is your child currently receiving OT, PT, ST,  or ABA? Do you know how much therapy your child gets a week and when their last evaluation was done? *
Is your child in or ever received ABA Therapy? *
What School District does your child reside in? *
What type of insurance does your child have? *
What educational environment is your child currently in? *
Do you feel their educational needs are being met? *
Are there any medical or behavioral concerns? *
What would you like us to know about your child? *
If we need to schedule a meeting with you and your child, is there a preferred day of the week and/or time of the day? *
How did you hear about The Lighthouse Center for Autism? *
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