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General Inquiry or
to Contact Us

Caregiver Information

First Name:

Last Name:

Phone Number:

Email:

Address:

City:

State:

Zip:

Do you have the right to authorize treatment? Yes / No

Child's Information

Child's First Name:

Child's Last Name:

Date of Birth:

Child's Age:

Gender: Male / Female

Does your child have a diagnosis? Yes / No

Please list:

Does your child have allergies? Yes / No

Please explain:

Does your child have a restricted diet? Yes / No

Please explain:

Is your child currently enrolled in a school program? Yes / No

Please complete the following:

Name of School

Current Grade:

Current Environment:

Classroom Setting:

General Education Setting
Specialized Classroom Setting

Who referred you to ABLE Academy?

What services are you interested in?

1:1 Therapy
Part Time Early Intervention
Full Time School Program
Social Skills Group Therapy

Therapy Services

Does your child currently receive any of the following services, or has he or she received them in the past?

Early Steps: Currently / In the Past

FDLRS: Currently / In the Past

Speech and Language Therapy: Currently / In the Past

Organization:

Therapist:

Occupational Therapy: Currently / In the Past

Organization:

Therapist:

Behavior Therapy (ABA Therapy): Currently / In the Past

Organization:

Therapist:

Communication

How does your child communicate with others?

Points or gestures
Uses sign language
Approximately how many signs does he/she use with meaning?
Single words
Approximately how many words does he/she use with meaning?
2-4 word phrases
Full sentences

Does your child communicate his/her wants and needs independently? Yes / No

Does your child answer questions appropriately? Yes / No

Receptive Language

Does your child consistently follow simple one step instructions? Yes / No

Does your child consistently follow complex or multiple step instructions? Yes / No

Can your child identify common objects in his or her environment when asked? Yes / No

Behavior

Does your child have any specific behavioral concerns? Yes / No

Explain:

Has your child ever tried to hurt himself/herself? Yes / No

Explain:

Is your child aggressive towards others? Yes / No

Explain:

Do you have additional concerns about your child’s behavior? Yes / No

Explain:

Social Interactions

Does your child socialize with peers? Yes / No

Does your child have friends? Yes / No

Academic Levels

Does your child read at grade level? Yes / No

At what grade level is he/she reading?

Is your child working at grade level in math? Yes / No

At what grade level is he/she performing?

General Information

Does your child have an IEP or 504 plan? Yes / No

Please select:

IEP Plan
504 Plan

Does your child qualify for the McKay Scholarship? Yes / No

Do you know your child’s matrix code?

Unknown / 251 / 252 / 253 / 254 / 255

Funding Information

Does your child qualify for the Step Up For Students Gardiner Scholarship? Yes / No / Not sure

Does your child have private insurance that covers ABA therapy? (Please note that ABLE Academy is in network with BCBS, however not all plans cover ABA therapy.) Yes / No / Not sure

Does your child have Medicaid coverage? Yes / No

Please enter the managed care group:

Will your child require additional scholarship funding? Yes / No

Will your child be self pay? Yes / No

* Please note that the McKay Scholarship, SUFS Gardiner Scholarship, insurance and other scholarship opportunities may not cover the full cost of your child’s programming. Scholarship funding is not guaranteed. *

Please detail any additional information or concerns that you may have:

5860 Golden Gate Parkway
Naples, Florida 34116
(239) 352-7600

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What We Do?
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