Your child's first name

Your child's date of birth

What is a good email address where we can reach the guardian of the child?

Has your child been diagnosed with autism?

If no, do they show signs of autism such as delayed language development, lack of eye-contact, repetitive behaviors such as rocking or spinning etc.

Is your child currently receiving any treatment for autism?

If yes, what kind and how much

If Other what?

How many hours a week?

Do you have the internet at home?

Do you have a computer at home?

Do you have access to a printer?

Do you have any questions for us?

If my child is selected to participate in this study, I understand that the parent, guardian, or the babysitter must be committed to following our individualized intervention plan for at least 30 min a day 5-6 days a week.

I understand that this intervention plan is made after a comprehensive assessment, is individualized for each participant and cannot be used with any other children.