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About Us
Services
Careers
Blog
Contact
Enroll Now
Start Your Child’s Journey
Select the Therapy services you need
In-Home ABA Therapy
Center-Based Programs
After-School Social Skills
ABA Prep for Families
Parent / Guardian Full Name
*
Relationship to Child
Please Select
Mother
Father
Grandparent
Stepparent
Foster Parent
Legal Guardian
Other
Email
*
Telephone
*
Preferred Contact Method
Call
Text
Email
Child full name
*
Date of birth
*
Gender
*
Male
Female
Primary address
*
Street Address
City
*
State / Province
*
Postal / Zip Code
*
Primary language spoken
*
Please Select
English
Spanish
Other
Does the child have an autism diagnosis?
*
Yes
No
Diagnosing provider name
*
Diagnosis date
*
Diagnostic evaluation (PDF)
*
Maximum file size: 32 MB
Primary Insurance Provider
*
Primary Insurance Provider
BCBS
Aetna
Cigna
United
Medicaid
Texas Children’s Health Plan
Superior
Tricare
Other
Member ID
*
Group Number
Policy Holder Full Name
*
Policy Holder Date of Birth
*
Relationship to Child
*
Please Select
Mother
Father
Grandparent
Stepparent
Foster Parent
Legal Guardian
Other
Upload Front of Insurance Card
*
Maximum file size: 10 MB
Upload Back of Insurance Card
*
Maximum file size: 10 MB
Do you have secondary insurance?
*
Yes
No
Insurance company name
*
Member ID
*
Policy type
*
HMO
PPO
EPO
POS
Medicaid Managed Care
Other
Group number
Policy holder full name
*
Policy holder date of birth
*
Upload secondary insurance card
*
Maximum file size: 32 MB
Pediatrician Name
*
Pediatrician Phone
*
Do you have a referral for ABA therapy?
*
Yes
No
Upload Referral Document (if available)
Maximum file size: 10 MB
Services Interested In
*
In-Home ABA
Center-Based ABA
Both
Preferred Start Timeframe
*
ASAP
Within 2 weeks
Flexible
Days Available
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Primary concerns
*
Communication delays
Behavior challenges
Social skills
Daily living skills
Other
How did you hear about us?
*
Google
Referral from Doctor's office
Community Event
Instagram/Facebook
Family/Friend
Other
Authorization to Verify Insurance Benefits
*
I authorize the provider to verify my insurance benefits and coverage for services.
HIPAA Acknowledgment
*
I acknowledge that I have received and reviewed the Notice of Privacy Practices.
Consent to Contact
*
Phone Call
Text Message
Email
Date
*
Submit
