Potential New Client - Seattle and Surrounding Areas
Clients
Greater Seattle Area
O.R.L. provides high quality Applied Behavior Analysis services to youth with autism in their homes and schools.
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First name
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Last name
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Email
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Phone number
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Your Child's Full Name:
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Your Child's Date of Brith:
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Does your child have a diagnosis of autism?
Yes
No
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Does Your Child Have Any Other Diagnoses? (Is yes, please list those)
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Your Telephone Number:
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Your Complete Address Including Your City and Zip Code
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Is Your Child Available Between 8:00 AM and 11:00 AM Most days to Receive ABA?
Yes
No
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Is Your Child Available Between 12:00 PM and 3:00 PM Most days to Receive ABA?
Yes
No
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Is Your Child Available Between 4:00 Pm and 7:00 PM Most days to Receive ABA?
Yes
No
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How much flexibility exists in when your child can be made available for ABA services?
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What Medical Insurance Does Your Child Use?
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Please Tell Us About Your Child's Language and Communication Skills
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Please Tell Us About Your Child's Social Skills
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Please Tell Us About Any Challenging or Problem Behavior Your Child May Display
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Please tell us any other information you'd like us to know about your child.
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Do you understand that by completing this form you are applying for services and that doing so does not guarantee that ORL will admit your child and that ORL does not provide any ABA services to any child without having a signed family contract on file?
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No
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