Client Initial Interest Form

Dear parents, caretakers, and families,

Thank you for your interest with Snowflakes ABA! If you are a returning family, welcome back! Please complete this initial interest form for families seeking services for their child ("client"). Please note the following

Complete one form for each child, as needed.
We have generally more daytime availability than afterschool and evening, due to clinician preferences and availability preferences
If you have a strict requirement that the RBT be of a certain gender, please answer that question below. Note: Most families do not have a gender requirement.

If Snowflakes can accept your child for services, we will follow up with formal intake and onboarding. If we cannot serve your child immediately, we will place your child on our waitlist.

Best regards,

Snowflakes ABA, LLC

Parent's name*

First NameLast Name

Parent's email*

example@example.com

Parent's phone*

Please enter a valid phone number.

Zip Code*

Child's name*

First NameLast Name

Child's age*

Child's Birthdate*

Date

Does your child have a diagnosis for autism?*

YesNot yet / In progressNoOther

Insurance*

Other Insurance: If other, what insurance(s) do you have?

What hours of availability do you have for your child? Select all that you can do:*

Mornings (9-12p)Afternoons (12-3p)After-school (3p and later)Other

Former client: Is this child a former client of Snowflakes ABA?*

YesNoOther

Gender Requirement for RBT: Do you have a strict gender requirement for the RBT?

Must be maleMust be femaleNo preference

Thank you for your interest in Snowflakes ABA!

Client Interest Form