Lead the Way Behavior Group

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Child's Full Name

Child's Date of Birth

Child's Gender

Relationship to Child

Home Address

Reason for care

What is the reason for seeking care?

E.g., potty training, behavior reduction, routines, self-help skills, etc.

Diagnoses Received, if applicable

Main Form of Communication

E.g., vocalizations, PECS, ASL, speech generating device, non-vocal, etc.

Problem Behaviors

Does your child engage in any of the following problem behaviors? Please check all that apply.

Aggression Towards Others (hitting, kicking, pinching, etc.) Tantrum Self-Injurious Behaviors (head banging, hitting self, biting self, etc.) Property Destruction (throwing, swiping, etc.) Biting Mouthing Elopement (running away) Minimal to no problem behavior Other

What are your child's strengths?

Administrative

Referral source

Enter how you heard about us.

Google Search Referral from doctor or another service provider Instagram Facebook Referral from another parent Other

Client Preferences

Preferred appointment times

Please select all times that you are available for services. Please Note: None of these times are guaranteed and final appointment times will be determined upon signing a service agreement.

Monday / Tuesday / Wednesday / Thursday 7 AM - 11 AM Monday / Tuesday / Wednesday / Thursday 11 AM - 3 PM Monday / Tuesday / Wednesday / Thursday 3 PM - 7 PM Friday 7 AM - 11 AM Friday 11 AM - 3 PM Saturday / Sunday 8 AM - 12 PM

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

Where do you want services to be provided?

We provide services in schools, in homes, and in community settings. Please provide the address of this location as well.

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.