Initial Interest Form
Thank you for your interest in receiving services at Mitchell's Place. This form must be completed in order for our intake coordinators to contact you with the next steps in the process.
Client's Name
*
Client's Birth Date
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Client's Gender
*
Male
Female
Other
Caregiver 1 Name
First Name
Last Name
Caregiver 1 relationship to client
*
Parent
Legal Guardian
N/A
Other
Caregiver 2 Name (if applicable)
First Name
Last Name
Caregiver 2 relationship to client
Parent
Legal Guardian
Other
If you have custody documentation, please upload:
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Primary Phone Number
*
Secondary Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company
Insurance coverage is subject to provider plan and treatment.
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What services has the client previously received or are currently receiving (through another provider)?
Applied Behavior Analysis (ABA)
Speech Therapy
Occupational Therapy
Feeding Therapy
Counseling/mental health therapy
Psychiatry
None
Other
What services are you interested in at Mitchell's Place? Please check all that apply.
*
Psychological Evaluation for autism diagnosis
Psychological Evaluation for another diagnosis (e.g., ADHD, OCD, ODD, dyslexia, specific learning disorder)
Early Learning Preschool (ELP)-Neurotypical student (age range 2-6 years)
Early Learning Preschool (ELP)-Autism Spectrum Disorder student (age range 2-6 years)
Applied Behavior Analysis (ABA) Therapy (age range 2-7 years)
Speech Therapy
Occupational Therapy
Feeding Therapy
Individual psychotherapy
Couples/family therapy
Psychiatry
Other
Has client undergone a previous evaluation for any developmental concerns?
*
No
Yes
Please upload a copy of client's previous evaluation(s):
*
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Did client receive a diagnosis?
Yes
No
What diagnosis did they receive?
Autism Spectrum Disorder (ASD), Level 1
Autism Spectrum Disorder (ASD), Level 2
Autism Spectrum Disorder (ASD), Level 3
Autism Spectrum Disorder (ASD), unknown level
Attention-deficit/hyperactivity disorder (ADHD)
Global developmental delay
Oppositional-defiant disorder
Language Delay/Disorder
Other
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Please provide information about client's current functioning.
How does client communicate with you?
Leading by hand
Pointing or reaching to items
Single words (e.g., "milk," "eat")
Short phrases/simple sentences (e.g., "I want milk," "more chips")
Complex sentences (e.g., "Can we go outside and play?")
Other
What age did client say his or her first words?
Do you notice speech issues, such as stuttering, slurring, or mispronunciations, when client speaks?
Which of the following skills can client do independently?
Dress self
Feed self with fingers
Feed self with utensils
Drink from an open cup
Independently use toilet
None
How often does your child become frustrated/upset?
Rarely (less than once per day)
1
2
3
4
Frequently (several times per day
5
1 is Rarely (less than once per day), 5 is Frequently (several times per day
How does client behave when he or she is frustrated?
Runs away
Yells
Hurts others
Hurts self
Whines
Cries
Falls to the ground
Other
Are there any times throughout the day that you see more disruptive behaviors (e.g., yelling, crying, hitting, falling to the ground, throwing items)? Please select all that apply:
Morning
Noon/lunchtime
Afternoon
Evening
My child does not engage in any disruptive behaviors.
Other
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Speech Therapy
Speech Therapy is the treatment of language and speech sound disorders. Our speech therapists work to increase the language that children understand, how children use language to communicate with others, and how to correct any speech sound errors. Mitchell's Place speech therapists see children up to age 12 with a variety of diagnoses (autism spectrum disorder, articulation disorder, language delay, developmental delay, etc.).
Once submitted, your information will be forwarded to the intake team at Mitchell’s Place. You will be contacted VIA EMAIL within 3-5 business days to discuss next steps in the application process. Be sure to check your spam folder if you do not receive an email. Please note submission of this form does NOT add client to the waiting list.
*
I acknowledge that I have read the above statement and want to be contacted about speech therapy services.
I am no longer interested in these services.
Occupational Therapy
You have indicated that you are interested in being added to the occupational therapy waitlist. Occupational therapy (OT) focuses on fine motor skills such as handwriting and cutting, in addition to self-care skills such as dressing and grooming. OT also works on sensory processing skills which allow children to be regulated throughout the day to help them participate in play and age-appropriate activities. Mitchell's Place occupational therapists see children up to age 12 with a variety of diagnoses (autism spectrum disorder, ADHD, sensory processing difficulties, etc.).
Once submitted, your information will be forwarded to the intake team at Mitchell’s Place. You will be contacted VIA EMAIL within 3-5 business days to discuss next steps in the application process. Be sure to check your spam folder if you do not receive an email. Please note submission of this form does NOT add client to the waiting list.
*
I acknowledge that I have read the above statement and want to be contacted about occupational therapy services.
I am no longer interested in these services.
Feeding Therapy
You have indicated that you are interested in being added to the feeding therapy waitlist. Mitchell’s Place offers individual feeding therapy with an Occupational Therapist or Speech Therapist. Mitchell's Place feeding therapy providers see children up to age 12 with a variety of diagnoses (autism spectrum disorder, ADHD, sensory processing difficulties, avoidant restrictive food intake disorder, etc.).
Once submitted, your information will be forwarded to the intake team at Mitchell’s Place. You will be contacted VIA EMAIL within 3-5 business days to discuss next steps in the application process. Be sure to check your spam folder if you do not receive an email. Please note submission of this form does NOT add client to the waiting list.
*
I acknowledge that I have read the above statement and want to be contacted about feeding therapy services.
I am no longer interested in these services.
Psychological Evaluation
You have indicated that you are interested in being added to the psychological evaluation waitlist. For more information about psychological evaluations, please visit: https://mitchells-place.com/evaluations/.
Once submitted, your information will be forwarded to the intake team at Mitchell’s Place. You will be contacted VIA EMAIL within 3-5 business days to discuss next steps in the application process. Be sure to check your spam folder if you do not receive an email. Please note submission of this form does NOT add client to the waiting list.
*
I acknowledge that I have read the above statement and want to be contacted about receiving a psychological evaluation.
I am no longer interested in these services.
Early Learning Program (ELP)-ASD slot
The Early Learning Program (ELP) is an ABA-based, classroom-based program for young children (up to age 6) with autism spectrum disorder (ASD) AND neurotypical peers. Students with ASD in the ELP are identified through an extensive screening process including the evaluation report from the psychologist or developmental pediatrician, the caregiver interview about the child’s areas of strengths and needs, and structured observations by the education director during a trial run within the classroom setting. The initial components of the screening process can help direct the intake staff to the appropriate placement for that child. Group learners usually, but not always, have a level 1 ASD diagnosis with mild to moderate language impairments, no accompanying cognitive impairments, and often have the ability to imitate motor skills and vocalizations. This has a high indication that the child will learn to follow instructions and respond well to prompting.
Once submitted, your information will be forwarded to the intake team at Mitchell’s Place. You will be contacted VIA EMAIL within 3-5 business days to discuss next steps in the application process. Be sure to check your spam folder if you do not receive an email. Please note submission of this form does NOT add client to the waiting list.
I acknowledge that I have read the above statement and want to be contacted about the ELP.
I am no longer interested in these services.
ELP-neurotypical slot
The Early Learning Program (ELP) is an ABA-based, classroom-based program for young children with autism spectrum disorder (ASD) and neurotypical peers. The initial components of the screening process can help direct the intake staff to the appropriate placement for that child.
Once submitted, your information will be forwarded to the intake team at Mitchell’s Place. You will be contacted VIA EMAIL within 3-5 business days to discuss next steps in the application process. Be sure to check your spam folder if you do not receive an email. Please note submission of this form does NOT add client to the waiting list.
I acknowledge that I have read the above statement and want to be contacted about the ELP.
I am no longer interested in these services.
Individual therapy/Marriage and Family Therapy
Mitchell's Place currently offers individual, family, and couples therapy services with a masters-level clinician. Presenting concerns may include emotion dysregulation, anxiety, behavioral difficulties, depression, family transitions, adjustment disorder, and social skills difficulties. These services are provided only at the Southside location and are typically self-pay.
Once submitted, your information will be forwarded to the intake team at Mitchell’s Place. You will be contacted VIA EMAIL within 3-5 business days to discuss next steps in the application process. Be sure to check your spam folder if you do not receive an email. Please note submission of this form does NOT add client to the waiting list.
I acknowledge that I have read the above statement and want to be contacted about individual psychotherapy or marriage and family therapy.
I am no longer interested in these services.
ABA Waitlist Submission
You have indicated that you are interested in being added to the ABA waitlist. Mitchell's Place offers two types of ABA Therapy:
You have indicated that your child is above the age-cutoff for ABA services at Mitchell's Place, which are available for children ages 2 to 7.
Please note that your child cannot be added to the ABA waitlist at this time. If there are others services in which you are interested, please continue submitting this form.
Please designate which ABA therapy program waitlist(s) you would like your child to be added to.
*
Focused ABA therapy (part time)
Comprehensive ABA therapy (full time)
Either Focused or Comprehensive ABA
I am no longer interested in ABA therapy.
My child is above the age cutoff for ABA therapy.
Thank you for your interest in Mitchell's Place. Please press submit below to complete this form.
If you have any other questions or comments, you may enter them here:
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