ALC Logo: Comprehensive ABA services for children with autism in Northern Virginia
Comprehensive ABA services for children with autism in Northern Virginia
Comprehensive ABA services for children with autism in Northern Virginia

Pre-registration Form

Service Requested:   

Child's Name:

Child's Birthdate:

Parent(s) Name(s):

Address: 

Home Phone:

Work Phone:

Email Address:

Diagnosis, Date Diagnosed, and By Whom: (detail please)

In current ABA program?  

Name of ABA program:

If yes, how long?

What school system is your child involved in?

Insurance Carrier:

How did you find out about ALC?

All information given to ALC, including this form, is confidential.