Autism (ABA) Form

Autism (ABA) Form

Thank you for your interest in Autism (ABA) Services at ErinoakKids! Registration is now open.
Please complete all required fields below (marked with *). If you have any questions or experience any issues, you may contact the ErinoakKids Intake team at 905-855-2690 (toll free 1-877-374-6625) and press 1 for support, from Monday-Friday, 8:00am to 5:00pm.

Child Information
First Name*
Last Name*
Date of Birth*

DayMonthYear
Has your child accessed ABA Services in the past 12 months?*

YesNo
Thank you for your interest. ABA services at ErinoakKids are available for children up to age 9. Please visit www.erinoakkids.ca/autism for information on autism services at ErinoakKids.

Primary Contact (this is the only person who will be contacted with service information and updates)
First Name*
Last Name*
Phone Number*
Please select phone type*
Please enter extension (if applicable)
Email*

Confirmation Email

Challenging Behaviour
Does your child exhibit challenging behavior on a daily basis?*

YesNo
If yes, please select all that apply*

AggressionSelf-InjuryElopement (running away)Property DestructionOther
Thank you. Your child may be eligible for our 1:1 ABA service. Please continue with the registration form.You may also be interested in our Urgent Response Service for children registered with the Ontario Autism Program. Learn more at www.erinoakkids.ca/urs.

Additional Information
Does your child tolerate when favourite items are not available or when they are told “no” without engaging in challenging behaviour (e.g., aggression, self-injury, elopement/running away)?*

YesNo
Can your child tolerate others (children/adults) in close proximity?*

YesNo
Can your child transition between preferred and non-preferred activities without engaging in challenging behaviour?*

YesNo

School Placement Status
What is your child's school placement status?*

1 child:1 adult1 adult:2 childrenMainstream integratedShared supportNot in school

Acknowledgement & Consent
- I understand that submission of this form does not guarantee an available spot; only that I will be contacted by ErinoakKids to determine next steps. I understand that the Terms of Engagement must be signed and payment collected once I am contacted by ErinoakKids to finalize registration.
- I understand this service includes either 1:1 or small group (2 children to one Clinical Therapist), and is not appropriate or applicable for children requiring more support.
- This information is being submitted with the knowledge and consent of the parents/legal guardians. By providing the contact information within the form, you consent to being contacted by ErinoakKids. ErinoakKids will always treat your personal details with the utmost care and will not share or sell your personal information. We are committed to keeping your information safe and confidential. We follow the rules set out in law about collecting, using, and disclosing your personal information. For more information, please review our privacy policies publicly posted at: erinoakkids.ca/privacy.
Consent Received*

YesNo
Consent must be received to submit this form.
Please verify that you are human*
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