Contact us for aba therapy If you are seeking any services from STEPS, please complete this initial part of our form: How did you hear about STEPS? What is your name and relation to the child? Email Address * What is your phone number? What is your child's name? What is your child's birthdate? Has your child already received intervention (ABA or another outside therapy such as Speech, OT, PT)? What kind? How long? What is your address, and what area/neighborhood are you in? This helps us account for commute times. What is your child's school placement (e.g. daycare, private school, public school, type of classroom? STEPS is an out-of-network provider. If your child has a diagnosis of autism, you may be able to submit our superbill to your insurance to seek partial reimbursement. Please check all timeframes Mon 8-12 Mon 12-3 Mon 3-6 Tues 8-12 Tues 12-3 Tues 3-6 Wed 8-12 Wed 12-3 Wed 3-6 Thurs 8-12 Thurs 12-3 Thurs 3-6 Fri 8-12 Fri 12-3 Fri 3-6 Sat 8-12 Sat 12-3 Sat 3-6 Sun 8-12 Sun 12-3 Sun 3-6 Please check all timeframes that your child is available for services. Times for therapy will occur during the below timeframes: Mon 8-12 12-3 3-6 Tues 8-12 12-3 3-6 Wed 8-12 12-3 3-6 Thurs 8-12 12-3 3-6 Fri 8-12 12-3 3-6 Sat 8-12 12-3 3-6 Sun 8-12 12-3 3-6 The following portion of our form allows you to complete information relevant to the specific services you are seeking. Feel free to fill out only the portions relevant to your child and family: ABA Therapy If you are interested in 1:1 ABA therapy, please check all options you would like to receive: In-Home ABA In-Clinic ABA (Our clinic is on Eastlake) In-School support Extra-curricular support (1:1 support during after-school activities) Facilitated Playdates School-based Services Please explain the purpose, location and participants you hope to include in a training or workshop: Groups What are your child’s strengths? How best does your child communicate (e.g. single words, sentences, sign language, pictures, communication device)? What does your child enjoy playing when he/she is playing alone? With peers? How does your child resolve problem situations (e.g. do they protest, ask for help, are they persistent with their communication attempts, resort to tantrums, or give up, etc.)? Does your child demonstrate any aggressive behaviors, either physical or verbal, towards him/herself or others? What tends to overwhelm your child? Can your child calm him/herself when upset or over-stimulated? How? Does your child have difficulty transitioning from one activity to the next? If so, how does he/she respond? Is your child toilet-trained? Does your child engage in elopement behavior (e.g. running off from an adult or group)? Has your child ever participated in a group before? If so, did he or she need 1:1 support? What are your priorities for your child that you would hope he or she would learn through participation in STEPS groups/summer program? Is there anything else we should know about your child? Caregiver Support If you are interested in parent education, please check all relevant topics with which you would like to receive support: Morning routines Mealtimes Evening Routines Toilet Training Compliance Challenging Behavior Community Outings Supporting Play and Peer Interactions Transitions Communication Generalization of skills Advocating for my child ABA Principles Positive Behavior Support (e.g. visuals, schedules, etc.) Please list any other specific areas of support you hope to receive: