Client Inquiry Form

Please complete the form below to join our client interest list and to receive more information about ABA Therapy for your child.

Caregiver First Name *

Caregiver Last Name *

Email *

Phone *

Full Address *

Alpharetta - 4080 MCGINNIS FERRY RD, SUITE 301, ALPHARETTA, GA 30005

Douglasville - 3136 GOLF RIDGE BLVD, DOUGLASVILLE, GA 30135

East Point - 1777 WASHINGTON RD, EAST POINT, GA 30344

Lithonia - 5280 SNAPFINGER PARK DR, DECATUR, GA 30035

Newnan - 1565 HWY 34 EAST, NEWNAN, GA 30265

Roswell - 1275 MINHINETTE DR, ROSWELL, GA 30075

Sandy Springs - 5163 ROSWELL RD, SANDY SPRINGS, GA 30342

Woodstock - 585 MOLLY LN, WOODSTOCK, GA 30189

I am seeking in home or community services only.

What is the best way to get in contact with you? *

Phone

Our main method of communication and fastest way to get in touch with us is via email.

Our team specializes in early intensive behavior intervention ABA therapy for children aged 1-5 diagnosed with Autism Spectrum Disorder.

What is your child's name? *

What is your child's date of birth? *

Our team specializes in early intensive behavior intervention ABA therapy for children aged 1-5 diagnosed with Autism Spectrum Disorder.

How old (years) is your child? *

Our team specializes in early intensive behavior intervention ABA therapy for children ages 1-5

What is your child's gender? *

Has your child been diagnosed with Autism Spectrum Disorder in the past 3 years? *

Yes

Yes, but we're waiting on a report from the doctor

If no, we may still be able to support your child. We will send referral sources for diagnosing pediatricians and psychologists who are experienced with ASD.

What was the date of their Autism Spectrum Disorder diagnosis? *

Who is your primary insurance provider? *

Who is your secondary insurance provider? *

Yes - I have already been approved for the Katie Beckett waiver

Yes - My application has been submitted

Yes - I'm planning to apply for it and understand I have to notify Dogwood Autism Services immediately after my application is submitted

No - I'm not planning to apply for it and understand I have to notify Dogwood Autism Services immediately if I decide to pursue it.

No - But I want more information and understand I have to notify Dogwood Autism Services immediately if I decide to pursue it.

Has your child ever received Applied Behavior Analysis (ABA) services before? *

Yes - weekly direct ABA therapy

Yes - caregiver training only (we never started direct therapy)

Yes - only completed an in-person ABA assessment (we never received any direct therapy or caregiver training)

I'm unsure

Our experience is, and research suggests, that a comprehensive ABA therapy model is the most effective way to achieve the desired goals for children ages 1-5. As such, we require that caregivers commit to the clinical recommendations of our Behavior Analysts to ensure your child's unique needs are met.

Are you willing/able to commit to 25 hours or more of direct therapy each week if clinically recommended by our Behavior Analysts? *

Yes

I am unsure. I would like further explanation on this commitment.

How did you hear about us?

Additional Information