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



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

  • 500 characters left.
4.

If you replied "other" in the last question, we can place you on a secondary interest list in the event we have more availability. 

Please describe your schedule needs if you would like to be placed on this list.

 

350 characters left.
5.

The APPLE Bothell Clinic plans to open in Early 2017. 

When is the earliest you are available to begin services?

January 2017
February 2017
March 2017
April 2017
Flexible
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:
Child's Age:
Insurance:

7.

Please select information requested.

More information
Intake Packet
Required 8.

We plan on expanding with Stepping Stones for Speech & Language Services (SLP) & Occupational Therapy (OT)  and with the Center for Child Development for Family, Individual Therapy & Diagnostic/Psychological Services.  Please see their websites for more information and also indicate below which services are of interest and we will forward that information to our collaborating providers:

SLP
OT
Family & Individual Therapy
Diagnostic/Psychologi-
cal Services
None
9.

Please select method preferred to be contacted.

Email
Phone
Morning
Mid-Day
Afternoon
Evening