Inquiry Form Please understand this form is for inquiry only and does not start services until I speak with the team. Your Name Your Email Address Your Phone Number I am completing this form as (parent, caregiver, self, school, medical, etc) Client Age Relationship to client? Where do you want services? (home, clinic, school, not sure) Best days and time to call? What concern do you have? When did these concerns start? What has helped so far? Has the client received ABA services before? Does the client have any diagnosis (autism, ADHD, developmental, anxiety, trauma, not sure) Any current support? Are there any safety concerns right now? Is anyone in immediate danger right now? How will services be funded? (insurance, medicaid, self-pay, other) Do you have any questions you want answered on the first call?
