Initial Inquiry Form

Initial Inquiry Form

Please complete the following form to apply for potential enrollment at Excel Prep. Once you have submitted the form, our team will evaluate your application and reach out with information on next steps.
Name of person completing application

First NameMiddle NameLast NameSuffix
Phone number of person completing application
Email of person completing application
Relationship to learner
Location
How soon are you looking to enroll this learner?
Referral Type
Referral Type
Reason for Referral
Reason for referral, please select all that apply:
Learner Information

Please complete this section
Learner Name

First NameMiddle NameLast NameSuffix
Learner's Date of Birth

MonthDayYear
Gender
Learner Current Grade
Physician Name
Primary Language
Learner Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Type of programming currently receiving:
Name of current school district
Name of current school
Has the child ever received ABA services in a clinic setting
Has the child ever received related services in a clinical setting? Check all that apply:
Please briefly describe current needs for this child:
Please provide a brief description of the child's areas of strength (i.e., daily living skills, academics, communication, etc.)
Please provide a brief description of areas in which the child struggles (i.e., daily living skills, academics, communication, etc.)
Guardian Contact Information
Primary Guardian Name

First NameMiddle NameLast NameSuffix
Primary Guardian Phone Number
Primary Guardian Email
example@example.com
Primary Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Learner's Medical History
Primary Diagnosis
Secondary Diagnosis (if applicable)
Has the child ever been hospitalized due to behavioral or emotional reasons?
Please list out any medications the learner currently takes
Example: Dextroamphetamine: 5 mg, takes it x2 daily at 8 am and 2:00 pm
Please list out any other important medical concerns we should be aware of:
Does the child have a seizure plan?
Tour Preference Date

Please let us know the preferred date and time for your tour.
Date

MonthDayYear
Date
File Upload

Please upload the following files for review if they are available.
Upload IEP (if applicable)

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Upload 3-Year Evaluation IEP (if applicable)

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Upload BIP (if applicable)

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Upload Evaluation to Support Diagnosis. This would be a diagnostic report.

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Upload Grades/Progress Reports (if applicable)

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Should be Empty:

Initial Inquiry Form

Referral Type

Reason for Referral

Learner Information

Guardian Contact Information

Learner's Medical History

Tour Preference Date

File Upload