Clinical Initial Inquiry Form

Clinical Services Initial Inquiry Form

Please complete the following form to apply for potential enrollment at Excel Learning. 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?
Learner Information

Please complete this section
Learner Name

First NameMiddle NameLast NameSuffix
Learner's Date of Birth

MonthDayYear
Gender
Learner Current Grade
Learner Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Referral Type
Referral Type
Reason for Referral
Please select all that apply:
Clinical Program Stage Needed
Primary Language
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:
What brings you to our program, and what goals are you hoping to achieve for your child?
Please describe the main concerns that led you to seek services, as well as what you are hoping your child will improve or work toward (for example: communication/language skills, social skills, behavior support, independence, academic skills, or daily living skills). You may also include your child’s strengths.
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
Has your child received a diagnosis of Autism Spectrum Disorder (ASD)?
Has the child ever been hospitalized due to behavioral or emotional reasons?
Please list out any other important medical concerns we should be aware of:
File Upload

Please upload the following files for review if they are available.
Upload Evaluation to Support Diagnosis. This would be a diagnostic report.

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Clinical Services Initial Inquiry Form

Learner Information

Referral Type

Reason for Referral

What brings you to our program, and what goals are you hoping to achieve for your child?

Guardian Contact Information

Learner's Medical History

File Upload