Please use the form below to request new services. We cannot always guarantee there will be an immediate spot available for your child in your selected program(s) but either way, an administrator will contact you as soon as possible.
Diagnosis or primary concerns
Person filling out form
Please check any therapies you are interested in
Location preference for therapies
Does your child qualify for the Early Autism Program? (Ages 2-4 with diagnosis of Autism or At Risk for Autism)
Yes and I would like this service
I'm not sure but would like information
No or not interested
Which Village would your child be in for ECA services?
Teal Village - Last name begins with A - L
Navy Blue Village - Last name begins with M - Z
Please check any Home and Community-Based services you are interested in
Which Village would your child be in for HCBS services?
Green Village - Last name begins with A - G
Yellow Village - Last name begins with H - P
Orange Village - Last name begins with Q - Z
If your child is 2 years of age through Kindergarten with a diagnosis of autism, would you like information about our ABA Autism Early Learning Center?
No or N/A
Cross Streets and City (to help us determine our availability in your area)
Preferred days and time frames for services (please check all that apply):
Please give details if there are specific times needed:
Attributes of the child or a potential provider to help us find a match (i.e. Child is a runner, Family has a dog, Provider must be familiar with GFCF diet, etc)
DDD Support Coordinator
Private Insurance Company
Questions or Comments
Should be Empty: