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Please complete the form below to apply to be on Emerald Coast Autism Center’s waitlist.
Is student vocal?*
Sign language?*
Augmented Communication Device?*
Briefly describe student's communication abilities
Describe maladaptive behaviors
Interest level*
Potty trained?*
Does your child have an IEP?
Military?
Insurance
Does insurance cover ABA services?
Completed by*
Date*
Additional Notes
