Request Services | The Sunshine Academy

Child's Full Name

Gender

Male

Female

Child's DOB

Child's Primary Insurance Provider

Child's Secondary Insurance Provider

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Email

Parent/Guardian Cell Phone

Parent/Guardian Address

Does Child have Autism Diagnosis?

Yes

No

If Yes, by who?

Child's Current School

School Category:

Special Ed.

General Ed.

Does your child have an IEP?

Yes

No

Additional Therapy Services Currently Receiving:

Speech Therapy

Occupational Therapy

Where are they attending for additional therapy services?

If your child has attended ABA therapy elsewhere, list ABA provider name:

Is there anything else you would like to tell us about your child that you feel might be helpful?

I agree to receive emails, calls, or texts from The Sunshine Academy about ABA services, updates, and resources. I understand I can opt out at any time.

I consent to the collection and use of the information provided in this form for the purpose of contacting me about ABA services for my child.

I acknowledge that the information provided may include protected health information (PHI) and consent to its use for initial evaluation and service coordination, as protected under HIPAA.

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Client Intake Form