ABA Coaching and BBC Interest Form

Please select the service you are interested in:*

Applied Behaviour Analysis (ABA) Coaching
Brief Behavioural Consultation (BBC)

If BBC was selected but the service is not suitable, would you consider ABA Coaching?*

Yes
No

Family Information

Caregiver Full Name:*

First Last

Child/Youth Full Name:*

First Last

Child/Youth Date of Birth:*

Email:*

Phone Number:*

Preferred contact method:*

Phone
Email

Language Preference:*

Does your child have a diagnosis of Autism Spectrum Disorder (ASD)?*

Yes
No

Is your child currently registered in the Ontario Autism Program (OAP)?*

Yes
No

Please specify your relationship to the child/youth (i.e., parent/guardian, service provider, etc.)*

Please indicate the topic(s) that you are interested in receiving consultation for (choose up to 3):*

Eating
Toilet Training
Sleep issues/concerns
New to ASD diagnosis
Life skills/resources
Social skills
School supports
Resource Kit/Visual Supports (e.g., visual schedules, token boards, choice boards, first-then boards, social narratives)
Challenging behaviours (e.g., aggression, property destruction, self-injury)

If Challenging Behaviours was selected above, please specify the behaviour(s) that you are looking for support with:

If Resource Kit/Visual Supports was selected above, please specify the resource(s) that you are looking for:

Based on the selections above, please indicate the highest priority goal for consultation:*

Consent

By completing this form, you certify that you are the primary caregiver of the child/youth which this form is being completed for. If you are not the primary caregiver, you confirm to have consent from the primary caregiver to complete this form. If you are not the primary caregiver or do not have consent from the primary caregiver and are looking to inquire about our services, please complete our ‘Request a Consultation’ form.

Child Profile

Communication (please select one that best describes your child/youth):*

Speaks fluently in full sentences and can discuss events that happen in the past or future
Speaks in two or three word phrases
Uses an alternative communication (e.g., sign language, picture exchange communication system, communication device)
Has no formal mode of communication (e.g., cries, pulls, points, pushes)

Independence (please select one that best describes your child):*

Completes tasks/routines (e.g., bathing, homework) that is typical of their age
Needs additional support from parents/caregivers to complete daily living tasks
Requires one-to-one support to complete most daily living tasks

Interfering Behaviours (please select all that apply):*

Aggression or property destruction (e.g., throwing, swiping, kicking, punching)
Self-injury
Elopement
Not applicable

Please list any health or medical conditions that may interfere with your child's learning (e.g., seizure disorder, anaphylaxis, anxiety, depression, ADHD)

Please share any additional information or other considerations we should be aware of (e.g., need for interpreter, upcoming changes, custody arrangements, cultural or religious considerations)

Please specify your preferred appointment time for questions/consultation:*

Morning
Afternoon
Evening
Any time

Please specify your preferred appointment day for questions/consultation:*

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Any day

CAPTCHA

ABA Coaching and BBC Interest Form

Information Collection Notice

Family Information

Child Profile

Stay Connected

This site uses cookies