ABA Therapy Registration – AUTISM MADE SIMPLE

Registration form ABA

Name

First Name

Last Name

Child's Date of Birth (DD/MM/YYYY)

Diagnosis Status

Parent/Guardian Full Name

Parent/Guardian Phone Number

Parent/Guardian Email Address

Services Requested

Preferred AMS Location

Please describe your child's strengths, challenges, and the main goals you would like us to work on.

Initial Consultation & Centre Tour

At Autism Made Simple, we offer an initial consultation
to discuss your child's individual needs, review your
family's goals, recommend suitable services, and provide
a tour of our centre.

Consultation Fee: $150

The consultation fee will be credited toward your
child's fourth paid therapy session after registration.

Registration and scheduling are subject to availability
and confirmation by our team.

Registration Deposit Agreement

I understand that the $150 initial consultation fee is required and will be credited toward my child's fourth paid therapy session after registration. I understand that registration and scheduling are subject to availability and confirmation by Autism Made Simple.

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AUTISM MADE SIMPLE

Initial Consultation & Centre Tour

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