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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

Is your child currently on our waiting list? 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
ADOS-2 Testing

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? (Please note that ABLE Academy does not participate with Medicaid or CMS.) 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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