Targeting Autism > Order Form

** All fields are required.

Parent Information:
NAME:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
E-MAIL:
PHONE:
Child Information:
CHILD'S FULL NAME:
AGE:
DIAGNOSIS, IF ANY:
DOES YOUR CHILD READ?	YES NO
Products & Services
Please choose a Product or Service (and complete the rest of the required information): YES NO - Presentation YES NO - Home Visit YES NO - Behavior Plan YES NO - Social Story YES NO - Visual Schedule YES NO - Task Analysis YES NO - Customized Vocabulary Sets YES NO - Receptive/Expressive Vocabulary Folder
Presentations: Getting To Know Autism Behavior Management Using Visual Strategies Fostering Positive Peer Interactions
Home Visit: Where would you like us to observe your child: At Home Outside the Home (If Outside the home, where? ) For what reason are you requesting a home visit? What dates and times are convienient for us to observe?
Behavior Plan: Please describe, as completely as possible, your behavioral concerns: Where and when does the behavior occur? What seems to trigger the behavior? What happens immediately after the behavior? What strategies have you tried in an attempt to change the behavior?
Social Story: Describe the situation for which you need a social story: Please provide as complete a description as possible of your child and any other people involved in the story so that we may choose the best picture to represent them in the story. You may also email photographs to us to help us make the right choice:
Visual Schedule: Describe the situation for which you need a visual schedule: Please break the schedule down into its most basic steps so we are sure to represent every aspect of it with our pictures. Look at the schedule through the eyes of your child! What size would you like the pictures to be? (Our standard size for a school or home schedule is about 1-3/4 inch squares, and for portable schedules, about 1 inch squares.) Please let us know if you prefer a different size.
Task Analysis: Which task analysis are you requesting? Please break the task down into its component steps. Be specific!! Look at this task through the eyes of a child!
Customized Vocabulary Sets: List the things your child likes to eat: List your child's favorite places to go: List your child's favorite toys: List things your child likes to do: List (and email us photographs of) important people in your child's life: List and name any pets in the home. Be sure to tell us the breed and color of the animal: What size would you like the pictures to be? (Our standard size for a vocabulary set is about 1-3/4 inch squares, and for portable sets, about 1 inch squares.) Please let us know if you prefer a different size.
Receptive/Expressive Vocabulary Folder: Which set (theme) of vocabulary folders are you requesting?

Free shipping on all products! 6% WV Sales Tax will be added to each order.

Your request will be processed by the staff of Targeting Autism. You will be contacted with invoicing information upon receipt and confirmation of the above information.

About Us | Contact Us | Products & Services | Photo Gallery