Parent Training Interest Form

1

Parent/Caregiver Name

First Name

Last Name

2

Child's Name

First Name

Last Name

3

RegionPlease select the region in which you are currently living or expect to receive services

4

EmailPlease provide the best email address to contact you

5

Phone NumberPlease include the best number to contact you

6

Since contacting Early Autism Services, have you begun receiving ABA Therapy (with any provider)?

YESNO

7

What is your availability for participation in caregiver training sessions?

Weekdays in the morning

Saturday or Sunday morning

Weekdays during lunch hour

Weekdays in the evenings

8

Please describe why you are interested in caregiver support:

9

How frequently would you be available for caregiver training sessions?

Intensive: multiple times per week

Weekly, once per week

Bi-weekly or semi-monthly

Once per month or fewer

10

Please include any questions or comments you may have for our clinical team.