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.

The program will take place over the course of 11 weeks. Sessions are 60 minutes in length. Groups run on a cyclical basis throughout the year.

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, Rensselaer, Saratoga, etc.):

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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. Is your family eligible for OPWDD and Family Support Services?

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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. Contact Information:

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* 9. Please select your preference for group meetings.

(Group meetings are 60 minutes in length.)

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