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Augusta Levy Behavioral Services Wait List Application

This is an application for Applied Behavior Analysis (ABA) services. Submitting this application does not guarantee placement or services. You must contact Augusta Levy Behavioral Services within three (3) business days if any information provided changes.

Questions or updates may be directed to Augusta Levy Behavioral Services at (304) 242-6722 or
augustalevylearningcenter@gmail.com.

Student Information

Student’s Name:

Student’s Date of Birth:

Child’s Age:

Address:

Parent / Guardian Information

Parent/Guardian:

Day Phone:

Cell Phone:

Evening Phone:

Email Address:

Employer:

Second Parent / Guardian (If Applicable)

Parent/Guardian Name:

Day Phone:

Email Address:

Additional Details

Siblings’ Names and Ages:

Insurance Carrier for Child’s Coverage:

Child’s Background and History

1) Local Education Agency (LEA your child would attend if in a public school program):

2) What is the student’s diagnosis?

3) Does the child have any additional diagnoses?

4) Who is the diagnosing physician?

5) Medications the student currently takes on a regular or as needed basis (include name, dosage, how often/when, and reason):

6) Are there any medications that will need to be administered at the center? (Please fill out medical release form if so):

7) Is your child receiving any additional services (Occupational Therapy, Speech, etc.)? Please list the services and how often the child receives the service:

8) Is the student currently enrolled in another program? If yes, what program?

9) Does the student have a current IEP (Individual Education Plan) in place?

10) Has the student attended any other programs or received any other type of intervention (at home or in another setting)? If yes, please describe:

11) Does your child have any diet restrictions? If yes, please describe:

Questions Related to Augusta Levy Behavioral Services

1) Does your child have any behavior issues? If yes, please describe:

2) Does your child have ongoing health issues? If yes, please describe:

3) What are your goals for the student?

4) What would be the times you would want your child to attend ALBS?

5) Augusta Levy Behavioral Services provides 30 hours of 1:1 ABA therapy to each student in the program. Are you willing and able to provide an additional 5-10 hours of 1:1 ABA therapy in your home (after adequate training by ALBS staff)?
YesNo

If no, please explain:

6) ALBS requires parents to attend parent-training sessions twice a month (one time every other week). Are you willing to participate in parent training sessions?
YesNo

If no, please explain:

7) While on the waitlist would you like to view parent training videos that focus on providing ABA in the home?
YesNo

8) Do you need any additional supports for resources in our community? If so what types of resources are you interested in?

Parent / Guardian Signature

Parent / Guardian Signature (Type Full Name):

Date: