Please complete this form to express interest in our virtual behavioral skills training program for parents. The goal of this program is to help parents learn techniques to reduce their children's challenging behaviors in the home.

In order to be eligible for this program, you must be (a) a parent or caregiver of a child with autism spectrum disorder between the ages of 3 and 12 years, and (b) a current resident of the Capital Region. Your family must also be eligible for OPWDD and Family Support Services.

This 8-week program includes weekly 60-minute sessions, with an optional weekly 30-minute troubleshooting session to provide personalized support.

We look forward to hearing from you!

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* 1. Your Full Name:

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* 2. Your Child's Full Name:

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* 3. County of Residence (Albany, Fulton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren or Washington)

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* 4. Child's Current Age in Years:

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* 5. Has your child been hospitalized within the past year due to his/her behavior?

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* 6. Does your child have OPWDD funding? (Have completed and been approved for the OPWDD services; must have TABS ID.)

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* 7. Does your family have Self-Direction for OPWDD and Family Support Services?

**NOTE: If your family has Self-Direction, please ensure that you add the program to your budget.**

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* 8. If you have one, please provide your TABS ID:

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* 9. Please provide some examples of what some of your challenging behaviors and when they occur.

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* 10. Contact Information:

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* 11. Please select your preference for group meetings.

(Group meetings are 60 minutes in length.)

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