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Early Start Denver Model-Based Program - Interest Form

Please complete this form to express interest in our virtual Early Start Denver Model-Based group program for parents. The goal of this program is to provide parents with training and tools to promote their child's social and communicative development.

In order to be eligible for this program, you must be (a) a parent or caregiver of an infant or toddler between 12-47 months old diagnosed or at genetic risk for autism spectrum disorder (b) be willing to participate in all training sessions and complete pre/post assessments.

The program will take place virtually on Zoom over the course of 12 weeks, starting Monday, September 14th. Sessions dates and times will be Mondays from 12-1.

We look forward to hearing from you!
1.Your Full Name:
2.Your Child's Full Name:
3.County of Residence (Albany, Rensselaer, Saratoga, etc.):
4.Child's Current Age in Months:
5.Is your child diagnosed with autism spectrum disorder (ASD)?
6.What is your child's primary method of communication?
7.If your child communicates verbally, please provide an example of a phrase or sentence they have used recently that demonstrates how they most frequently communicate.

If your child does not yet communicate using words or phrases, please provide an example of the way they most frequently communicate (e.g., pull your hand to what they want).
8.Contact Information:(Required.)