Enrollment Inquiry Form

Parent/Guardian Information

First Name

Last Name

Relationship to Child

Phone Number

Email Address

Address

City

State:

Zip Code

Do you have the right to authorize treatment?

Yes

No

Who referred you to ABLE Academy?

Services Interested In

ADOS Testing
1:1 - Early Intervention ABA Therapy
Full-time Early Intervention Therapy
Full-time School Program

Child's Information

Child's First Name

Child's Last Name

Date of Birth

Age

Gender

Does your child have a diagnosis?

Yes

No

Is your child on a special diet?

Yes

No

Is your child currently on our waitlist?

Yes

No

Is your child currently enrolled in a school program?

Yes

No

Current School Program

Name of School

Speech and Language Therapy

Never

Currently

In the Past

Occupational Therapy

Never

Currently

In the Past

Behavior Therapy

Never

Currently

In the Past

Other Therapy

Never

Currently

In the Past

Communcation & Behavior

What is your child's primary form of communication?

Points and Gestures
Signs
Approximately how many signs does he/she use with meaning?
Single Words
Approximately how many words does he/she use with meaning?
2-3 Word Phrases
Complete Sentences

Can your child identify common objects in his or her environment when asked?

Yes

No

Does your child independently communicate their wants and needs?

Yes

No

Does your child answer questions appropriately?

Yes

No

Does your child consistently follow simple one-step instructions?

Yes

No

Does your child consistently follow complex or multiple-step instructions?

Yes

No

Does your child have any specific behavior concerns?

Yes

No

Has your child ever tried to hurt themselves?

Yes

No

Is your child aggressive towards others?

Yes

No

Does your child socialize with peers?

Yes

No

Does your child have friends at school?

Yes

No

Does your child have friends outside of school?

Yes

No

Does your child read at grade level?

N/A

Yes

No

Is your child working at grade level in math?

N/A

Yes

No

At what grade level are they working?

Does your child have an IEP or 504 plan?

Yes

No

Insurance and Funding

Does your child have private insurance that covers ABA therapy?

* Please note that insurance coverage only applies to early intervention ABA therapy. ABLE Academy participates with BCBS. However, not all plans provide coverage for ABA therapy.

Yes

No

Does your child have Medicaid Coverage?

* Please note that insurance coverage only applies to early intervention ABA therapy. ABLE Academy does not participate with CMS.

Yes

No

Does your child currently receive funding through the Family Empowerment Scholarship - Unique Abilities?

ABLE Academy only participates with the FES-UA scholarship with Step Up for Students as the funding source.

Yes

No

Payment Information

ABLE Academy’s programming consists of fee-based services. Therapy charges and/or tuition fees are invoiced to families monthly. Please indicate your funding preference for costs above and beyond insurance coverage or SUFS funding amounts.

Additional Information

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

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