ABA Coaching Interest Form Home | ABA Coaching Interest Form Information Collection Notice This intake form is used to determine suitability of service and prepare for our initial contact with you. Family InformationCaregiver Full Name:* First Last Child/Youth Full Name:* First Last Child/Youth Date of Birth (DD/MM/YYYY):*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email:* Phone Number:*Preferred contact method:* Phone Email Language Preference:*Does your child have a diagnosis of Autism Spectrum Disorder (ASD)?* Yes No Is your child currently registered in the Ontario Autism Program (OAP)?* Yes No Please specify your relationship to the child/youth (i.e., parent/guardian, service provider, etc.)*Please indicate the topic(s) that you are interested in receiving consultation for (choose up to 3):* Eating Toilet Training Sleep issues/concerns New to ASD diagnosis Life skills/resources Social skills School supports Resource Kit/Visual Supports (e.g., visual schedules, token boards, choice boards, first-then boards, social narratives) Challenging behaviours (e.g., aggression, property destruction, self-injury) If Challenging Behaviours was selected above, please specify the behaviour(s) that you are looking for support with:If Resource Kit/Visual Supports was selected above, please specify the resource(s) that you are looking for:Based on the selections above, please indicate the highest priority goal for consultation:*Consent By completing this form, you certify that you are the primary caregiver of the child/youth which this form is being completed for. If you are not the primary caregiver, you confirm to have consent from the primary caregiver to complete this form. If you are not the primary caregiver or do not have consent from the primary caregiver and are looking to inquire about our services, please complete our ‘Request a Consultation’ form.Child ProfileCommunication (please select one that best describes your child/youth):* Speaks fluently in full sentences and can discuss events that happen in the past or future Speaks in two or three word phrases Uses an alternative communication (e.g., sign language, picture exchange communication system, communication device) Has no formal mode of communication (e.g., cries, pulls, points, pushes) Independence (please select one that best describes your child):* Completes tasks/routines (e.g., bathing, homework) that is typical of their age Needs additional support from parents/caregivers to complete daily living tasks Requires one-to-one support to complete most daily living tasks Interfering Behaviours (please select all that apply):* Aggression or property destruction (e.g., throwing, swiping, kicking, punching) Self-injury Elopement Not applicable Please list any health or medical conditions that may interfere with your child's learning (e.g., seizure disorder, anaphylaxis, anxiety, depression, ADHD)Please share any additional information or other considerations we should be aware of (e.g., need for interpreter, upcoming changes, custody arrangements, cultural or religious considerations)Please specify your preferred appointment time for questions/consultation:* Morning (8 a.m. – 12 p.m.) Afternoon (12 – 4 p.m.) Evening (4 – 8 p.m.) Any time Please specify your preferred appointment day for questions/consultation:* Monday Tuesday Wednesday Thursday Friday Saturday Any day How did you learn about this service? (Please check all that apply)* Access OAP York Simcoe Autism Network Kinark Autism Services Website Kinark Staff Marketing Materials (e.g., Brochure, Flyer, Poster) Kinark Service Guide Email Newsletter Google Search Kinark Open House Community Event Another Community Agency / Organization Physician or other Healthcare Professional School Board Social Media (e.g., Facebook, Instagram) Personal Contacts (e.g., Friends, Family Members) Conferences Other Please specify the community event:*Please specify the community agency/organization:*Please specify the conference:*If "other," please specify:*CAPTCHA