Enrollment Application

You will need to provide the following outside of this application

Report/evaluation confirming diagnosis of Autism Spectrum Disorder (ASD)

Most recent physical examination (must be completed by PCP within the past 12 months)

Any other recent evaluations the child has had completed (i.e. school, speech, OT, neurological, etc.)

An up-to-date record of all immunizations the child has had

If insurance is involved, pre-authorization is required prior to any evaluation, therapy, or any other service being provided

In-take interview

VB-MAPP completed by BAWMI staff

Meeting with BCBA to discuss goals and program plan

Arrangement of therapy schedule

The following is required so that we can best meet the physical, intellectual, behavioral, and emotional needs of your child and family. The information provided will remain confidential in accordance with HIPPA laws.

Personal Information

Child's Name(Required)

Child's Date Of Birth(Required)

Parent(s)/Guardian Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent 1 Phone Number(Required)

Parent 1 Email(Required)

Parent 2 Phone Number(Required)

Parent 2 Email(Required)

When did your child receive a medical diagnosis of Autism Spectrum Disorder?(Required)

Date of Evaluation/Name of Evaluator(Required)

Center location choice for services(Required)

Personal Information

Insurance Information

Education Information

Additional Services

Medical & Behavioral Health History

Parent Questionnaire

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