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Aut sm BEHAVIORAL SOLUTIONS
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Service Inquiry Questionnaire
What is your name?
How old is the individual you are seeking services for?
What is your session availability?
Morning (8am-12pm)
Afternoon (12:30-4:30pm)
Full Day (8am-4:30pm)
Has the individul had ABA therapy before?
Yes
No
Why are you seeking ABA services?
Do you reside in one of the following service areas? (Alexandria City, Arlington County, Fairfax County, Washington D.C.)
Yes
No
Do you have insurance coverage through one of the followng providers? (United, Blue Cross Blue Shield, Medicaid (Anthem), Medicaid (United))
Yes
No
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