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Service Interest Form
When are you available for services? (select all that apply)
Mornings (8:30-11:30)
Early Afternoons (12-3)
Late Afternoons (3:30-6:30)
Does the patient have a formal diagnosis?
No
Yes, Diagnosed with Autism Specturm Disorder
Yes, Diagnosed as AT RISK for Autism Spectrum Disorder
Yes, Other Diagnosis (please describe below in additional comments)
What are you looking for?
ABA Services for a patient with an Autism diagnosis
ABA Services for a patient with suspected Autism or other diagnosis
Referral for Diagnostic Testing
Referral for Counseling (please describe below in additonal comments)
Other (please describe below in additonal comments)
I understand CCBS provides ABA as an intensive service with 9 to 40 hours a week being required based on my child’s needs which will be determined by a BCBA after assessments are completed
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