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Please complete the form below to apply to be on Emerald Coast Autism Center’s waitlist.
Are you interested in learning more about Emerald Coast Learning Center for private school services?
Gender*
Is student vocal?
Augmented Communication Device?
Potty trained?
Briefly describe maladaptive behaviors
Briefly describe student's communication abilities
Eligible for FESUA?*
Do they have insurance covering ABA in case 1:1 services are needed in clinic?*
If yes, please list insurance
Additional Notes
