Early Autism Services: Therapy Qualification Form

Submission Date

Date

Child's First Name*

Child's Age*

Select Your Location*

Select Your State*

At this time, for children over the age of 10, Early Autism Services offers Remote Caregiver Training. Please select below if you would like to participate in Remote Caregiver Training.

Caregiver Training*

YES - I would like to receive caregiver training.NO - I would not like to receive caregiver training.

Does your child have a formal autism diagnosis?*

YesNoIn progress

Please provide the date your child's assessment is scheduled.*

Date

Insurance Type*

CommercialMedicaidTricareOut of Pocket

Therapy Preference*

Center-Based TherapyIn-Home Therapy

Select Your County (Alabama)*

If you are not located within any of the counties provided, please select which county you would be willing to drive to for center-based services. (If applicable.)

Select Your County (Georgia)*

Select Your County (Idaho)*

Select Your County (Illinois)*

Select Your County (Indiana)*

Select Your County (Maryland)*

Select Your County (Michigan)*

Select Your County (Missouri)*

Select Your County (Oregon)*

Select Your County (Tennessee)*

Select Your County (Virginia)*

Alabama: Please select your desired therapy center location in Alabama.*

Illinois: Please select your desired therapy center location in Illinois.*

Michigan: Please select your desired therapy center location in Michigan.*

Oregon: Please select your desired therapy center location in Oregon.*

Tennessee: Please select your desired therapy center location in Tennessee.*

Georgia: Please select your desired therapy center location in Georgia.*

Virginia: Please select your desired therapy center location in Virginia.*

Maryland: Please select your desired therapy center location in Maryland.*

Parent/Guardian Name*

First NameLast Name

Phone Number*

Email*

Preferred Method of Contact*

PhoneEmailText Message

Please select at least 3 time blocks you are able to fully commit to for therapy sessions. (Select all that apply.)*

	9am-Noon	Noon-3pm	3pm-6pm
Monday
Tuesday
Wednesday
Thursday
Friday

Time Blocks Selected

Hours of Therapy Selected

Yes Option

Yes

No Option

No

Qualified Intake

YesNo

Insurance Accepted

YesNo

Jotform Fake Email

example@example.com

How did you hear about us?

Patient Information

Parent/Guardian Information