• 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 
    • Date of Birth*
       / /
    • Has your child accessed ABA Services in the past 12 months?*

    • 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) 
    • Format: (000) 000-0000.

    • Challenging Behaviour 
    • Does your child exhibit challenging behavior on a daily basis?*
    • If yes, please select all that apply*

    • 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)?*
    • Can your child tolerate others (children/adults) in close proximity?*
    • Can your child transition between preferred and non-preferred activities without engaging in challenging behaviour?*
    • School Placement Status 
    • What is your child's school placement status?*
    • Daily Living Skills 
    • Is toilet training a goal you have for your child (this goal can only be targeted in a 1:1 setting)?*
    • Is food selectivity a goal you have for your child (this goal can only be targeted in a 1:1 setting)?*
    • Service Selection 

    • Your child is eligible for the below service(s). Please indicate the service(s) you are interested in and specify your preferences therein.

      Note: For the Fall semester, Small Group Services, if applicable, are only available for two (2) half-day sessions per week

    • What is your preferred site to receive ABA Services? (select all that apply)*
    • What is your preferred schedule for receiving ABA Services? (select all that apply)*
    • What is your preferred frequency per week of ABA Services? (select all that apply)*
    • What is your preferred site to receive ABA Services? (select all that apply)*
    • What is your preferred schedule for receiving ABA Services? (select all that apply)*
    • 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*

    • Consent must be received to submit this form.

    • Should be Empty: