2021 Easterseals Hawaii ABA Services Request Form

If you are interested in ABA services, please complete this form.

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* 1. Child's full legal name

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* 2. Child's birthdate

Date / Time

Date

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* 3. Child's gender

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* 4. Please provide your city and zip code:

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* 5. Who is your insurance provider?

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* 6. Please indicate your preferred service type:

Parent-Led Parents and caregivers learn the basics of Applied Behavior Analysis (ABA) via coaching from a highly skilled team in order to implement ABA programming with their child.

1:1 Clients meet individually with a practitioner, either in one of our clinics, in their home, or another location in the community.

Parent Education (accompanies 1:1 services) Parents / caregivers meet approximately two times per month for one hour, guided by Applied Behavior Analysis (ABA) professionals. Topics covered include understanding autism, positive approaches to managing challenging behaviors, increasing behaviors you want to see more of in your child, and much more.

Group Applied Behavior Analysis (ABA) Two or more clients meet with one or more behavior analysts to improve their cognitive and social skills.

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* 7. Please indicate your child's school day start time:

Time

AM/PM

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* 8. Please indicate your child's school day end time:

Time

AM/PM

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* 9. Please tell us your preferred session days/times (ex: Mon-Fri, 9 AM to 2 PM):

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* 10. Does your child currently receive or have they previously received ABA services?

Yes