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Date of Request(Required) MM slash DD slash YYYY Section A:Name(Required) First Last OAP#DOB(Required) MM slash DD slash YYYY AGE(Required)Gender(Required)Address(Required) Street Address City Province Postal Code Diagnosis/Diagnoses(Required)Name of School/DaycareSection B: Parent(s)/Legal GuardianName(Required) First Last Address(if different)Primary Phone(Required)Secondary PhoneEmail(Required) Name First Last Address(if different)Primary PhoneSecondary PhoneEmail Custody(Required) Both Mother Father Other Section C: Service Preference (Select all that apply)Service Preference(Required) Applied Behavior Analysis Individual Service(individual or Group based) Occupational Therapy Speech/Language Services Mental Health Services Section D: Current Needs/GoalsWhat are your top three goals for your child? Please be specific.1.(Required)2.3.Section E: Funding and ServicesWe Receive(Required) Special Services at Home Funding Assistance for Children with Severe Disabilities funding OAP Funding Not currently receiving any funding Do you need information on how to access funding?(Required) Yes No I would like more information(Required) Yes No By completing this form you are acknowledging that you will be added to the Autism Services email distribution list. Your email address will only be used for the purpose of communicating with you about Autism programs and services, and will not be shared with a third party. You can contact us to opt out of the distribution list at anytime.
