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Request a 15 minute consultation:

Looking for support for your child? Tell us a little about your family and what brings you to Blume.


This brief form helps our team understand the general reason for your inquiry and determine whether a 15-minute introductory consultation with Blume may be an appropriate next step. Please avoid sharing detailed clinical, medical, educational, or other sensitive information through this form.

Parent / Caregiver information

Preffered language
English
Spanish

Tell us about your child:

Where Do You Live?
Does your child have an IEP?
Has your child received a diagnosis or clinical recommendation related to ABA services?*

Please do not include diagnosis details or medical records in this form. Relevant clinical information can be discussed securely during the intake process, if appropriate.

Tell Us What Brings You to Blume

Are you satisfied with your child’s current progress at school?
Yes, I am satisfied with their progress.
Somewhat, but I still have concerns.
No, I am concerned about their progress.
I’m not sure.
What concerns do you currently have about your child’s school experience? Select all that apply.
What brings you to Blume at this time? Select all that apply.

ABA Services

What type of ABA services are you interested in? Select all that apply.
How are you looking to access ABA services?
Private Pay
NYC DOE-Funded / Special Education Authorization
I am currently working with an attorney regarding ABA services
I’m not sure

IMPORTANT: Blume does not provide legal advice or legal representation. Any decision to consult with or retain an attorney is made independently by the family. Attorney fees and services are determined directly between the family and the attorney.

How soon are you looking to begin services?
As soon as possible
Within the next 30 days
Within 1–3 months
More than 3 months from now
I’m not sure yet
I’m currently gathering information

Anything Else We Should Know?

Please do not include diagnoses, medical records, educational records, identifying information about third parties, or other sensitive or confidential information in this form.

What Happens Next?

Once your request is submitted, our team will review the information you provided. If a consultation appears to be an appropriate next step, a member of the Blume team will contact you to coordinate a 15-minute introductory call.


Submitting this form does not guarantee acceptance for services, coverage, funding, or provider availability and does not establish a provider-client relationship. The consultation is introductory and does not constitute a clinical evaluation, diagnosis, treatment recommendation, or legal consultation.

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