Virtual Group Screening Form

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Virtual Group Screening Form

Information Collection Notice: This intake form is used to determine clinician assignment, suitability of service, and prepare for our initial contact with you. The information collected will be stored in your child’s confidential client record and will only be accessible by those actively involved with your service.

Instructions: Please complete the following if your child appears to be a good fit for the group based on the information provided. A Board Certified Behavior Analyst (BCBA) will contact you to schedule a virtual screening of your child to confirm suitability.

  • Parent / Caregiver Information

  • Child Information

  • Office and Technology Requirements

  • Caregiver Requirements

  • Child Requirements and Prerequisite Skills

  • Considerations for Group Learning

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