Spectacular Kids ABA Academy Registration Form

To begin our intake process, please complete the form below.

ABA Private School Registration

Client Registration

Free Text

1. Student Information

First Name

Last Name

Middle Name

Date of Birth

Gender

Does your child have a diagnosis of autism?

Yes

No

Who diagnosed your child?

Date of most recent diagnosis of autism?

Does your child have any other diagnosis?

Is your child currently enrolled in school?

Reason for seeking new school placement?

Is there anything else you would like us to know about your child?

How did you hear about us?

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2. Family Information

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Please provide complete contact info for at least one parent.

Primary's Name*

Primary Contact*

Relation to the student

Primary Contact(First Name)

Primary's Phone Number*

Primary's Email*

Address

Primary's City

Primary's State / Province

Primary's Postal / Zip Code

3. Services

Current Placement

Indicate where the child's current placement is?

Current Therapy Services

Speech Therapy

Occupational Therapy

Physical Therapy

Psychological Services

Other

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We will contact you to gather additional information.

Spectacular Kids ABA Academy Registration Form

ABA Private School Registration

Client Registration

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