Intake form

 At ABA Next Steps, we offer individualized educational and vocational training to maximize the potential for teens and young adults with autism and related developmental disabilities to lead productive and more independent lives. We are pleased to announce that we are accepting applications for open enrollment. Please note that completion of this intake form does not guarantee admission into ABA Next Steps. All applications are carefully considered in the order they are returned. Pre-applicants will be contacted to take a tour of the program and submit the full application prior to enrollment. As placement may fill quickly, we encourage prospective student interns to submit this initial intake form as early as possible to start the enrollment process.

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Prospective Student intern

Name *

First

Last

Date of birth *

MM/DD/YYYY

Mailing Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Email *

Phone *

Parent/Caregiver

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

currently the have

Email *

Email

Confirm Email

Phone *

Relationship to student intern *

With whom does the student intern reside? *

Do you have legal custody of the student intern? *

• Yes
• No

Does anyone else have legal rights regarding the education or treatment of the student intern? *

• Yes
• No

Medical information

Allergies *

Diagnoses *

Current medications *

Ongoing Medical Conditions or Concerns *

Does the student intern require any special accommodations? *

Educational History

Is the student intern currently enrolled in school?

• Yes
• No

If so which school?

Grade?

Has the student intern ever received ABA Therapy?

• Yes
• No

If so, what were the approximate dates?

If currently receiving ABA Therapy, please list current provider:

Additional Information:

Does the prospective student intern currently engage in any of the following behaviors?
*Please note- Behaviors do not exclude a student intern from this program

Aggression Towards Others *

• Yes
• No

Property Destruction/Disruption *

• Yes
• No

Self Injurious Behavior *

• Yes
• No

Tantrum *

• Yes
• No

Elopement *

• Yes
• No

Non-Compliance *

• Yes
• No

Self-Stimming *

• Yes
• No

Please add anything else you think we should know

Submit