A.P.P.L.E. Consulting Bothell Clinic Survey
RequiredRequired Question(s)
Required 1.

APPLE Consulting's Bothell Clinic will have 3 session blocks per day.  Please select which session option would work best for you and your child.

Morning (5 days per week): 8:30-11:30
Mid-Day (5 days per week): 12-3
Afternoons (M,W,F) 3:45-6:15
Afternoons (T,Th) 3:45-6:15
  • Comment:

  • 500 characters left.
Required 2.

If the selected session block above is not available, please rank the session blocks based on your schedule preferences.  "1" is your most preferred session; "4" is your least preferred time. 


(1 = Most Preferred)
 
Mornings (5 days per week): 8:30-11:30
Mid-Day (5 days per week): 12-3
Afternoons (M,W,F): 3:45-6:15
Afternoons (T,TH): 3:45-6:15
3.

 

The APPLE Bothell Clinic prefers sessions to be 5 days per week for most blocks to ensure quality of care and intensity needed based upon the research for ABA intervention.  Priority will be given to those who are able to meet the 5 day per week requirements.
If the 5 day per week blocks are a barrier for you, please rank in order of preference: 1 - most preferred; 3 - least preferred

For other, please indicate schedule preference in the comments below.


(1 = Least)
 
Mornings: Less than 5 days per week
Mid-day: Less than 5 days per week
Other
  • Comment:

  • 500 characters left.
4.

Please tell us which insurance you have.

 

350 characters left.
5.

APPLE plans to have OT/SLP & Psychological Services provided by our partners, Stepping Stones and the Center for Child Development.  Please indicate which services are of interest:

SLP
OT
Psychological
None
Required 6.

In order for us to communicate with you, we will need some basic information.

(We will not use your personal information for any other purpose other than to contact you for the Bothell Clinic.)


First Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com
City:

7.

Please select information requested.

More information
Intake Packet
8.

Please select method preferred to be contacted.

Email
Phone
Morning
Mid-Day
Afternoon
Evening