Name of person filling out form:*

Your Email:*

School:*

Student Name:*

What type of request is this? (Please select one)

New contract for the 21-22 school yearContract change for the 21-22 school year

Would you like to discuss services with a director before filling out this form? (If you select "Yes", you may skip to the bottom to click SEND NOW and a director will contact you within 1 business day.)
—Please choose an option—No Thanks - I can fill it out nowYes Please - I'd like to chat first

Date you would like contracts to begin:

Hours you would like to contract with S^D for program services delivered by a Behavior Instructor supervised by a Behavior Analyst:

Three spaces per day are provided in the event you need services in 3 different locations in a single day. Please input the total number of hours per day per location.

Monday
Location: —Please choose an option—SchoolSd OfficeRemote     Hours:
Location: —Please choose an option—SchoolSd OfficeRemote     Hours:
Location: —Please choose an option—SchoolSd OfficeRemote     Hours:

Tuesday
Location: —Please choose an option—SchoolSd OfficeRemote     Hours:
Location: —Please choose an option—SchoolSd OfficeRemote     Hours:
Location: —Please choose an option—SchoolSd OfficeRemote     Hours:

Wednesday
Location: —Please choose an option—SchoolSd OfficeRemote     Hours:
Location: —Please choose an option—SchoolSd> OfficeRemote     Hours:
Location: —Please choose an option—SchoolSd OfficeRemote     Hours:

Thursday
Location: —Please choose an option—SchoolSd OfficeRemote     Hours:
Location: —Please choose an option—SchoolSd OfficeRemote     Hours:
Location: —Please choose an option—SchoolSd OfficeRemote     Hours:

Friday
Location: —Please choose an option—SchoolSd OfficeRemote     Hours:
Location: —Please choose an option—SchoolSd OfficeRemote     Hours:
Location: —Please choose an option—SchoolSd OfficeRemote     Hours:

Date you would like services to start:

Is this a request for 2 Behavior Instructors:

For clients that are served in either an S^D location or solely remotely we can provide Special Education Services. This is not available for students who are served in a hybrid model in their sending school and remotely. We also can not supplement Speech and Language Services or Special Education services being received by a school provider at this time.

Would you like Special Education Services from S^D Associates:

If yes, how many sessions per week (sessions are in 30-minute increments):

Would you like Speech and Language Services from S^D Associates:

If yes, how many sessions per week (sessions are in 30-minute increments):

Transportation (Please select one)

School or parent will be providing transportationWe are requesting transportation from Sd services

Any additional notes:

Please initial after each of the following 3 items to confirm you have read and understood the information they contain.

I understand for each day of services remote and face to face the contract will include 1.5 hrs of Behavior Analyst Time, .5 hrs of Behavior Instructor Prep Time, $10 a day for consumables: curriculum consumables, reinforces, PPE, educational supplies.:

I understand that that the contract can be changed by the 20th of each month by submitting a change form through this portal. If not, the old contract will be charged until the following month.:

I understand that this is a request for a contract and that a director will confirm that the contract request can be fulfilled and then the business office will send the itemized contract along with a service agreement to be signed before starting services.: