Enrollment Inquiry English Español If you would like to learn more about how FirstSteps services may be right for your child, please complete this form or simply give us a call at 1.800.819.FSFK. About you Guardian First Name Guardian Last Name Guardian Email Guardian Phone May we leave a message? YesNo Preferred contact method EmailPhone City of residence Preferred FS Location —Please choose an option—Redondo BeachWest LAEast LANorth LAWalnut Creek About your child If you have more than 1 child in need please list all here separated by a comma Child First Name(s) Child Birthdate(s) Have any of your children in need been diagnosed with ASD or related diagnosis? Your Family’s Needs What are your child’s greatest areas of need? When thinking about your child’s treatment and education, what is most important to you? When thinking about your child’s future, what is most important to you? Treatment Considerations How did you learn of FirstSteps? Treatment Services of Interest —Please choose an option—Individual 1:1 InterventionGroup LearningTargeted TreatmentTelehealth Our program is based on scientific research which consistently indicates that best child-outcomes are achieved when ABA treatment is delivered in early childhood, and intensively (25+ hours per week), with parents included and active in Is at least one caregiver willing and able to participate in your child’s treatment program? YesNoUnsure Is your child able to receive a high level of weekly treatment hours as determined via individualized assessment? YesNoUnsure Care Team Does your child have an IEP (if yes, write in School District and school attending)? Are you working with your local Regional Center (if yes, write in Regional Center you are working with)? Health Insurance Carrier Does your plan include ABA Benefits for the treatment of ASD? YesNoUnsure Any other overall comments or info we should know about (optional)
