T.E.A.M. Habilitation & Respite

Train, Enrich, Accommodate, Mainstream

Request Services

If you are interested in in receiving services please take a moment to complete this form and an intake specialist will be contacting you.

Name (Optional) Age *Contact Person *Phone Number *Email Address *Diagnosis *Major Cross Roads *Mailing Address *Services Required
Habilitation
Respite
Behavioral Consulting / Parent Coaching
ABA/AVA Habiltiation
DES/DDD Authorized for services
Yes
No
Pending
Support Coordinator's Name Is Client Toilet Trained Is Client Verbal Any Special Training Required Forms of Communication
Sign Language
PECS
Augmented Communication Devise
Picture Schedules
Other non-verbal form of communication not listed
Any special Sensory issues you would like your provider to be aware of? Allergies Any Special Devices utilized for communication or for activities of daily living? Example, augmented communication, walker? History of Seizures, if yes, how are they managed? Any Special Interests Any Dislikes What do you use or what would you like to use as reward or incentives? Describe the client's personality Any additional information we may need to be aware of while working with the client? Example, food or religious restrictions? Anything more you'd like to add?

Privacy Policy

T.E.A.M. Habilitation & Respite does not disclose personal or health information to unaffiliated third parties. We follow HIPPA and all Federal Laws regarding Personal, Private, Health Information. If you have any questions or concerns about the T.E.A.M. Habilitation & Respite’s Privacy Policy or its implementation, you may contact us at (480) 816.1866.