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First Name*

Last Name*

Email Address*

Phone*

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?

Are you currently receiving Access OAP funding?* Are you currently receiving Access OAP funding?* Yes No, I am not eligible Waiting on my funding

What is your child's First and Last Name*

Age of Child/Youth/Adult* Age of Child/Youth/Adult* 4-6 7-9 10-12 13-15 16-18 Over 18

How did you hear about us at Brightside ABA Services?*

What type of Services are you interested in? (check all that apply)* What type of Services are you interested in? (check all that apply)* One to One (in-home) One to One (in-centre) One to One (telepractice) Group Services (in-centre) Parent Training (telepractice) Consultation (adult services)

You selected 'One to One'. How many hours of service are you looking for per week?* You selected 'One to One'. How many hours of service are you looking for per week?* Maximum 2 hours per week 3-5 hours per week 6-10 hours per week

If you move ahead with services, what time of day are you looking for ABA to be? (choose all that apply) Note: we do not offer weekend services* If you move ahead with services, what time of day are you looking for ABA to be? (choose all that apply) Note: we do not offer weekend services* Morning (8:30 - 12:00) Afternoon (12:00 - 5:00) Evening (5:00-7:00) *Note: there may be additional delay in receiving services due to limited availability

Does the child/youth/adult engage in any of the following? (choose all that apply)* Does the child/youth/adult engage in any of the following? (choose all that apply)* Self-harm Harm to others (kicking, hitting, biting, etc.) Action to objects (throwing, etc.) Yelling/Screaming Inappropriate sexual behaviour None of the above

What type of goals are you hoping to work on? (choose all that apply)* What type of goals are you hoping to work on? (choose all that apply)* Executive Functioning (e.g. problem solving, organization/planning) Managing Challening Behaviour Social Skills (e.g. responding to questions, initiating conversations, joining in on conversations, 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

When would be a good time to contact you? (choose all that apply)* When would be a good time to contact you? (choose all that apply)* Morning Afternoon Evening

What would be the best way to contact you? (choose all that apply)* What would be the best way to contact you? (choose all that apply)* Email Phone

Do you provide consent to be added to our newsletter. We use the newsletter to inform families of upcoming service offerings and opportunities. Do you provide consent to be added to our newsletter. We use the newsletter to inform families of upcoming service offerings and opportunities. Yes No