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First Name*

Last Name*

Email Address*

Phone*

Are you receiving Ontario Autism Funding?* Are you receiving Ontario Autism Funding?* Yes No

Please indicate which type of Ontario Autism Funding:* Please indicate which type of Ontario Autism Funding:* Core Clinical Funding One-Time-Interim Funding Waiting for funding

Do you Reside in Waterloo Region?* Do you Reside in Waterloo Region?* Yes No

You answered 'No' to the above question. Please indicate where you reside?

Age of Child/Youth/Adult* Age of Child/Youth/Adult* 0-4 5-6 7-9 10-12 13-15 16-17 18+

Does the child/youth/adult engage in any of the following?* Does the child/youth/adult engage in any of the following?* Self-harm Harm to others (kicking, hitting, biting, etc.) Harm to objects (throwing, etc.) Yelling/Screaming Inappropriate sexual behaviour Other

Please elaborate on what other things does your child engage in?*

What type of goal are you hoping to work on?* What type of goal are you hoping to work on?* Executive functioning (e.g. problem solving, organization/planning) Managing challenging behaviour Social skills (e.g. responding to questions, initiating conversations, joining and ending conversations) Communication skills Play skills (e.g. turn taking, sharing, winning/losing) Self-regulation skills Vocational skills (e.g. job skills, interview skills, etc.) Knowledge based goals (e.g. relationships and dating) Unsure Other

What other type of goal are you hoping to work on?*

What type of service(s) are you interested in?* What type of service(s) are you interested in?* One to One (in-home) One to One (telepractice *dependent on goal) Dyad (in-centre) Group (in-centre) Parent Training (telepractice) Unsure Other

When would be a good time to contact you?* When would be a good time to contact you?* Morning Afternoon Evening

What would be the best way to contact you?* What would be the best way to contact you?* Phone Email

What time of day is your preference for your intervention sessions? (Indicate all that apply)* What time of day is your preference for your intervention sessions? (Indicate all that apply)* Morning (8:30-12:00) Afternoon (12:00 - 4:00) Evening (4:00-7:00) *note there may be additional delay in receiving services due to limited availability

Receive future communications from Brightside ABA Services Receive future communications from Brightside ABA Services Yes, I'd like to receive future notifications from Brightside on upcoming services options