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702-461-4403
shootingstarsfoundation@outlook.com
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702-461-4403
shootingstarsfoundation@outlook.com
Intake Form
Name
*
Email address
*
Type of support needed
Please select at least one option.
Funding Assistance
ABA Therapy
Community Outreach
Resource Information
Age of child
Select
Under 2
2-5
6-10
11-15
16-18
Preferred contact method
Select
Email
Phone
Video Call
Additional family members affected
Do you have previous experience with support services?
Select
Yes
No
What are your primary concerns?
Please select at least one option.
Communication
Behavior
Social Skills
Daily Living Skills
How did you hear about us?
Select
Referral
Social Media
Website
Event
Which service or services are you interested in?
Please select at least one option.
Comprehensive ABA therapy
Additional questions or comments
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