Let’s work together Name of Parent/Caregiver * First Name Last Name Email * Phone * (###) ### #### Does your child have an Autism diagnosis by a physician? * Yes No Unsure When was your child born? MM DD YYYY What insurance do you have? * Blue Cross Blue Shield Aetna Magellan Healthcare Other Available times for therapy (check all that apply) * Schools commonly recognize ABA therapy as a medically necessary service and excuse student absences accordingly when an Autism diagnosis is present. Mornings (8:00-12:00) Afternoons (12:00-5:00) How did you hear about us? * Referral from friend/family member Facebook Instagram Online search (Google, Bing, etc) Event or conference Referred by a professional Word of mouth Drove by Other Authorization to Contact * By checking this box, you provide consent to be contacted by phone or email and to receive intake documentation necessary for initiating the ABA therapy application process. Message If there is any other relevant information you wish to share, please include it here. Thank you!A member of our team will be contacting you shortly to continue the application process.
