FUNction Junction ABA Program Application

You will complete the application in three (3) phases:

Phase 1: Fill out this form below. This form will get routed to the ABA Program director, who will direct the office to reach out to you to set up a parent interview.

Phase 2: Fill out, upload and submit the necessary documents, including an ASD diagnosis and IEP, if applicable. You can submit those documents here.

Phase 3: Attend the parent interview and ABA assessment. This determines the plan of care and if your child is a good fit for the program. We want your child to thrive in the environment. So a good fit is crucial.

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- Step 1 of 10

Let's Learn A Little Bit About You...

Parent's Name *

First

Last

Parent's Email *

Parent's Best Phone

Phone Type

Mobile
Home
Work

Address

Address Line 1

Address Line 2

City

State

Zip Code

Child's Information

Child's Name *

First

Last

Child's Birthdate *

Layout

Insurance Carrier *

Member/Subscriber 1D#

Are you currently receiving services at Therapy Smarts? *

Yes
No
We have in the past.

Which Services does your child receive from us? (check all that apply) *

Speech
Occupational
Physical
Feeding
Aquatic

Is your child currently receiving ABA therapy with another clinic or company? *

Yes
No, never
In the past

What is the name of the ABA clinic/company?

How many hours of ABA therapy were they prescribed each week?

Selected Value: 10

Typically, patients are prescribed between 15-40 per week.

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Let's Learn More About Your Child.

Just take a few minutes to complete the quiz, fill out some information and check all the boxes that apply. (This take approximately 15 minutes.)

Let's get started!

My Child's Age is *

Child Out of Range

Sorry, at this time, our program is only available for children between the ages of 2 to 10 years old.

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So Let's Talk About Your Child's Big Movements...

My Two Year Old...

(check all that apply)

My Three Year Old...

(check all that apply)

My Four Year Old...

(check all that apply)

My Five Year Old...

(check all that apply)

My Six Year Old...

(check all that apply)

2 year old Gross Motor Development

Stoops down to retrieve toy and returns to standing
Jumps down off low surface, such as curb at the park
Jumps forward about 4 inches
Goes up stairs without rail (placing both feet on each step)
Throws a ball 3 feet in air
Kicks ball 3 feet forward without direction
Rides a push bike (bike without pedals)

3 Year Old Gross Motor Development

Walks up stairs without rail (one foot on each step)
Rides a tricycle
Hops 3 times on one foot
Kicks a large ball towards a target
Jumps down about 24 inches
Slides down a slide at the playground
Climbs well on a jungle gym
Able to stop quickly when running

4 year old Gross Motor Development

Stands on one foot for 5 seconds (hands on hips)
Hops 5-8 times on each foot
Rides a 2-wheeled bike with training wheels
Walks backwards on a line over 4 feet
Jumps forward 30 inches
Climbs well on a jungle gym
Walks downstairs without using a rail, placing one foot on each step

5 year old Gross Motor Development

Completes sit ups
Able to skip, alternating feet
Completes jumping jacks
Completes push-ups
Performs somersaults
Climbs well on jungle gym
Has begun to jump rope
Throws the ball to hit a target
Swings without being pushed
Pumps legs to keep the swing going

6 year old Gross Motor Development

Runs with coordination
Completes sit ups
Able to skip
Completes jumping jacks
Rides a 2-wheeler without training wheels
Completes push-ups
Performs somersaults
Climbs well on jungle gym
Is able to jump rope
Throws the ball to hit a target
Swings without being pushed
Pumps legs to keep the swing going

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Now, Let's Talk About Your Child's Small Movements...

My Two Year Old...

(check all that apply)

My Three Year Old...

(check all that apply)

My Four Year Old...

(check all that apply)

My Five Year Old...

(check all that apply)

My Six Year Old...

(check all that apply)

2 years Fine Motor Development

Drinks from regular open cup that does not have a lid or spout
Drinks from a straw using lips
Looks at picture books by themselves
Zips and unzips zippers if someone latches it for them to get them started
Takes off their own clothes
Uses play dough, paint and paper
Scribbles without going off paper
Builds a 4-6 block tower
Able to put a simple, large puzzle piece into a wooden puzzle
Can feed self with a spoon or fork
Imitates drawing a vertical line
Puts square, round and triangular shapes into board or a shape sorter

Fine Motor Development for 3-Year Olds

Grasps pencil with thumb and fingers instead of fist
Screws and unscrews jar lids
Eats with a fork (with spillage)
Pours accurately from one container to another
Completes a simple 3 piece puzzle
Can dress and undress with loose clothing and with help to get the clothing facing the correct way
Able to hold scissors and snip on paper
Able to draw straight lines or circles
Snips (makes small cuts) with scissors
Can stack up several blocks

Fine Motor Development for 4-Year Olds

Puts socks on correctly
Puts shoes (does not yet tie) on correctly
Buttons and unbuttons quarter inch buttons, such those on a button down shirt
Colors almost entirely within lines of circle
Able to draw a circle and straight lines independently
Draws a person with 3 different body parts (e.g. head, arms, legs or head, eyes, mouth)
Dresses and undresses without much help
Copies a cross
CAN string ½ inch beads onto a lace
Can use a fork and spoon well

Fine Motor Development for 5-Year Olds

Holds crayons or pencils with thumb and fingers
Copies and cuts a square
Copies color/shape sequence
Latches and zips the zipper on their coat
Traces around own hand with crayon
Completes simple dot to dot pictures
Able to copy a couple letters
Puts socks on correctly
Cut along a straight line
Able to draw a circle, square and cross (+)
Able to put on shirts, pants, socks, and shoes (with some help with fasteners)
Able to feed himself well with a spoon and fork

6 years Fine Motor Development

Dresses and undresses self
Reads and writes numbers one to 10
Writes first and last name
Ties shoes
Draws a person with six different body parts
Colors within lines
Open zip lock bags and food wrappers
Cuts out simple shapes with scissors

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My 18 Month Old...

(check all that apply)

My 2 Year Old...

(check all that apply)

My 3 Year Old...

(check all that apply)

My 4 Year Old...

(check all that apply)

My 5 Year Old...

(check all that apply)

My 6 Year Old...

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2 year Old Speech Development

Frequently uses 2 word phrase such as ("more cookie," "no juice," "mommy book").
Uses some one- or two- word questions ("Where kitty?" "Go bye-bye?" "What's that?").
Demonstrates verbal turn taking
Has at least 50 words
Understood by listeners 25-50% of the time
Follows simple 2 step commands, such as "pick up your ball and put it in the toybox"
Eats table foods with mixed textures such as, cut up green beans, small pieces of chicken, and pasta
Listens to simple stories, songs, and rhymes
Points to a few body parts when asked.
Points to pictures in a book when named.
Uses many different consonant sounds at the beginning of words.

3 Year Old Speech Development

Has about 1000 words
Converses in sentences -- Uses two or three words to talk about and ask for things
Ask questions such as "What is that? Where did mommy go?" why?
Responds to "what" and "where" questions
Understood by listeners 75% of the time
Can follow 3 step verbal commands, such as "pick up your blanket, take it upstairs and put it on your bed"
Uses k, g, f, t, d, and n sounds.
Understands differences in meaning ("go-stop," "in-on," "big-little," "up-down").
Listens to and enjoys hearing stories for longer periods of time
Chews and swallows most adult foods including steak and raw veggies

4 Year Old Speech Development

Uses at least 1500 words
Uses 4-5 word sentences
Understands time concepts of now/later, before/after, first/then
Uses contractions (don't)
Asks many questions including "who" and "why"
Understood by listeners 80% of the time
People outside of the family usually understand child's speech
Follows multi-step directions, such as "go upstairs, brush your teeth, put on your jammies and pick out a book"
Chews and swallows most adult foods including steak, raw veggies
Talks about activities at school or at friends' homes.
Talks about what happened during the day. Uses about 4 sentences at a time.
Says rhyming words, like hat-cat
Uses pronouns, like I, you, me, we, and they
Uses some plural words, like toys, birds, and buses
Uses a lot of sentences that have 4 or more words.
Usually talks easily without repeating syllables or words.
Hears you when you call from another room.
Hears television or radio at the same loudness level as other family members.
Understands some colors and shapes
Understands words for family, like brother, grandmother, and aunt

5 Year Old Speech Development

Uses a variety of sentences
Vocabulary of 2000 words
Can tell a story with plot
Understood by listeners 90-100% of the time
Asks questions to get more information
Understands time concepts (today tomorrow, yesterday)
Uses contractions, such as don't and can't
Chews and swallows most adult foods including steak, raw veggies
Says all speech sounds in words. May make mistakes on sounds that are harder to say, like l, s, r, v, z, ch, sh, th.
Responds to "What did you say?"
Talks without repeating sounds or words most of the time
Names letters and numbers
Uses sentences that have more than one (1) action word, like jump, play, and get. May make some mistakes, like "Zach got two video games, but I got one."
Keeps a conversation going
Talks in different ways depending on the listener and place. May use short sentences with younger children or talk louder outside than inside.
Understands words for order, like first, next, and last.
Hears and understands most of what is said at home and in school.
Follows multi-step directions, such as "go upstairs, brush your teeth, put on your jammies and pick out a book"
Follows classroom directions, like "Draw a circle on your paper around something you eat."

6 years Speech Development

Uses a variety of sentences
Vocabulary of 2600 to 7000 words
Can tell a story with plot
Understood by listeners 90-100% of the time
Asks questions to get more information
Uses more speed sounds correctly
Engages in play with others
Uses pronouns correctly(I, me, you, he, she, they)
Understands time concepts (today, tomorrow, yesterday)
Uses contractions such as don't, wouldn't, and can't
Follows multi step directions such as take off your shoes, hang up your coat, take your folder out of your backpack, and put your lunch box on the counter.
Chews and swallows most adult foods including steak, raw veggies

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Now, Tell Us How Meal Times Are Going...

My 2 Year Old...

(check all that apply)

My 3 Year Old...

(check all that apply)

My 4 Year Old...

(check all that apply)

My 5 Year Old...

(check all that apply)

My 6 Year Old...

(check all that apply)

Early Feeding Concerns

Coughing or choking during eating
Arching or stiffening of the body during feeding
Being very irritable/fussy during or after feeding
Taking a really long time to eat a meal (more than 30-45 minutes)
Frequent spitting up
Getting sick often with pneumonia or chest infections
Gurgly, hoarse, or breathy voice after eating
Less than normal weight gain or growth
Lots of leakage of food or liquid from the mouth
Coughing, gagging, or throwing up during or after meals
Has a limited diet -- does not eat a wide variety of foods for their age
Stuffing mouth with food
Holding food inside pockets in mouth for long periods
Difficulty accepting new textures of food
Avoidance behaviors to specific foods and textures (gagging, vomiting, blocking the spoon with hands or closed lips, crying, pushing food away, etc)
Abnormal bowel movements that last longer than a few days (diarrhea, constipation, loose stool)
Skin reactions to foods (dry patches, hives, raHe/shes) Note: If your child seems to be having a severe allergic reaction to a food (difficulty breathing, turning red, developing hives or rash on the face/chest), you should seek medical help immediately

Feeding Concerns

Regular coughing or choking during eating
Refuses to eat what is served at dinner making mealtimes stressful
Taking a really long time to eat a meal (more than 30-45 minutes)
Getting sick often with pneumonia or chest infections
Gurgly, hoarse, or breathy voice after eating
Less than normal weight gain or growth
Lots of leakage of food or liquid from the mouth
Coughing, gagging, or throwing up during or after meals
Stuffing mouth with food
Holding food inside pockets in mouth for long periods
Difficulty accepting new textures of food
Avoidance behaviors to specific foods and textures (gagging, vomiting, blocking the spoon with hands or closed lips, crying, pushing food away, etc)
Refusing to eat more than a few foods, or refusing to eat anything from one of the food groups
Being extremely rigid about how food is prepared or how it is served
Abnormal bowel movements that last longer than a few days (diarrhea, constipation, loose stool)
Skin reactions to foods (dry patches, hives, raHe/shes) Note: If your child seems to be having a severe allergic reaction to a food (difficulty breathing, turning red, developing hives or rash on the face/chest), you should seek medical help immediately
Has a limited diet -- does not eat a wide variety of foods for their age

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Next, Tell Us About Your Child's Response to How They Sense The World Around Them...

My 2 Year Old...

(check all that apply)

My 3 Year Old...

(check all that apply)

My 4 Year Old...

(check all that apply)

My 5 Year Old...

(check all that apply)

My 6 Year Old...

(check all that apply)

Early Sensory Integration

Cries during bath time or refuses to take a bath
Cries or fights when you try to brush their hair or teeth
Does not turn towards sounds
Does not show an interest in watching people's faces
Does not smile back at me when I smile at them
Does not point at objects to show interest (point at an airplane flying over) by 14 months
Makes very few gestures (such as pointing, waving, showing)
Does not play "pretend" games (e.g. pretend to "feed" a doll) by 18 months
Doesn't seem to know how to play with toys or excessively lines up toys or other objects
Is attached to one particular toy or object
Avoids messy play
Avoids eye contact
Wants to be alone 75% of the time
Avoids being held and snuggled or resists physical contact
Becomes easily upset, compared to other children their same age
Is not able to calm down easily after being upset
Unusual prosody (rhythm and intonation of language talks in a flat, robot-like, or sing- song voice)
Is frightened by typical sounds such as the vacuum or a toilet flushing
Refuses to eat what is served at dinner making it a stressful time for the family.
Refuses to try new foods
Is unable to sit down to perform an activity, look at a book, or play a game
Is not comforted by others during distress
Gives unrelated answers to questions
Gets upset by minor changes
Has obsessive interests
Flaps his hands, rocks his body, or spins in circles
Avoids climbing and exploring at the playground
Has unusual reactions to the way things sound, smell, taste, look, or feel
Grinds their teeth
Has flat or inappropriate facial expressions
Has a loss of speech or babbling or social skills
Gets dizzy or car sick easily
Does repetitive movements with objects
Avoids wearing different types of clothing textures, or is very particular about the feel of the clothing they wear
Has a lack of sharing interest or enjoyment with others
Lack of appropriate eye gaze
Inconsistent or no response to name
Is not cooperative for their age
Is particular about what socks they wear, or insists on wearing them inside out
Appears to be anxious
Seems to be in constant motion, seems to be unable to sit still, unless playing on an electronic device
Follows a rigid routine and has difficulty with changes in routine (e.g. Dad is picking them up from daycare one day instead Mom or insists on taking a specific route to school)
Has difficulty adapting to any changes in schedule or environment (e.g. throws a tantrum if the furniture is rearranged or bedtime is at a different time than usual)

Sensory Integration

Cries during bath time or refuses to take a bath
Avoids messy play
Cries or fights when you try to brush their hair or teeth
Prefers not to be touched, held, or cuddled
Has trouble understanding or talking about feelings
Doesn’t know how to connect with others, play, or make friends
Appears disinterested or unaware of other people or what’s going on around him
Doesn’t seem to hear when others talk to her
Doesn't share interests or achievements with others (drawings, toys)
Repeats the same words or phrases over and over
Responds to a question by repeating it, rather than answering it
Avoids looking at you or others in the eye when being spoken to
Uses facial expressions that don't match what he/she is saying
Doesn’t pick up on other people’s facial expressions, tone of voice, and gestures
Makes very few gestures (such as pointing)
May come across as cold or “robot-like”
Reacts unusually to sights, smells, textures, and sounds
May be especially sensitive to loud noises
Abnormal posture, clumsiness, or eccentric ways of moving (e.g. walking exclusively on tiptoe)
Unusual attachments to toys or strange objects such as keys, light switches, or rubber bands
Obsessively lines things up or arranges them in a certain order
Preoccupation with a narrow topic of interest, often involving numbers or symbols (e.g. memorizing and reciting facts about maps, train schedules, or sports statistics)
Spends long periods of time arranging toys in specific ways, watching moving objects such as a ceiling fan, or focusing on one specific part of an object such as the wheels of a toy car
Repeats the same actions or movements over and over again, such as flapping hands, rocking, or twirling
Is not able to calm down easily after being upset
Is unable to sit down to perform an activity, look at a book, or play a game
Avoids climbing and exploring at the playground
Grinds their teeth
Avoids wearing different types of clothing textures, or is very particular about the feel of the clothing they wear
Is particular about what socks they wear, or insists on wearing them inside out
Gets dizzy or car sick easily
Doesn’t play "pretend" games, engage in group games, imitate others, or use toys in creative ways
Appears to be anxious
Speaks in an abnormal tone of voice, or with an odd rhythm or pitch (e.g. ends every sentence as if asking a question)
Seems to be in constant motion, seems to be unable to sit still, unless playing on an electronic device
Follows a rigid routine and has difficulty with changes in routine (e.g. Dad is picking them up from daycare one day instead Mom or insists on taking a specific route to school)
Has difficulty adapting to any changes in schedule or environment (e.g. throws a tantrum if the furniture is rearranged or bedtime is at a different time than usual)

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Next, Tell Us About Your Child's Behavior...

Has this behavior occurred within the last two weeks? (Check all that apply)

Eloping (ex: running away from adult or designated area)
Aggression (ex: hitting, kicking, scratching, biting others)
Self-injury (ex: hitting, biting, scratching self)
Task refusal (refusing to dress, engage in educational or therapeutic activities, take a bath, etc.)

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Finally, Tell Us About Your Pediatrician...

Child's Pediatrician Name *

First

Last

Pediatric Clinic Name

Pediatric Clinic Location/Address

Address Line 1

Address Line 2

City

State

Zip Code

Pediatrician's Phone Number

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Review Application

This application is NOT a guarantee into the ABA Therapy Program at Therapy Smarts and is merely a first step.

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