Areas We Serve

Wichita, Kansas & Surrounding Areas

Phone

970-310-6540

Email

Connect

Image of a mom smiling with her two younger children, sitting at a table together, filling out an intake form.

Intrest Form

We’re so glad you’re here. Please complete the form below if you are interested in Applied Behavior Analysis Therapy services. This is not a formal intake, this helps us learn more about your child and determine next steps.

Caregiver's Name

Child's Name

Child's Birthday

Address

Phone

Has your child received Applied Behavior Analysis therapy before?

What is your child's current health insurance?

Is you child's primary insurance KanCare/Medicaid?

What service(s) are you most interested in?

Community Outings

Telehealth Sessions

In-home Sessions

In-Office Sessions (Clearwater, KS)

Combination of all of them

Does you child have an Autism Spectrum Disorder Diagnosis?

Yes

In the process of getting a diagnosis

What level was your child's diagnosis?

Level 1

Level 2

Level 3

My child's Psychological Evaluation that was completed in the lst 5 years. (if yes please check the box)

How was your child diagnosed?

Pyschological Evaluation

Diagnosed by a Neurologist

Diagnosed by a Medical Doctor

Other

Does your child currently engage in any of the following? (Select all that apply)

Aggression (hitting, kicking, biting)

Self-injury

Elopement (running away)

Frequent tantrums or meltdowns

None of the above

What are your main concerns for your child right now?

Consent

My child and I are able to participate in theapy 1-8 hous per week. (Hours will be determined based on level of Autism diagnosis and scheduling)

I understand this form is a request for services and does not guarantee immediate availability. I consent to being contacted by Behavioral Training Solutions.

Behavioral Training Solutions, LLC

Play-Based ABA Therapy for Children with Autism
Caregiver Support & Education
Training for Educators

Areas We Serve

Phone

Email

Connect

Intrest Form

Thank you for submitting! We will contact you soon.