Registration

ABA Therapy Registration Form

We’re excited to connect with you and learn more about your child and their unique needs. Please complete the registration form below to help us get to know your family and understand how we can best support you. Once we receive your information, a member of our team will reach out to you about the next steps.

Phone

This field is for validation purposes and should be left unchanged.

Child's Name(Required)

First Last

Parent/Guardian's Name(Required)

First Last

Email

Phone

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of Birth(Required)

Select Age Group(Required)

Ages 3-5

Ages 5-8

Ages 9-12

Do you plan to use health insurance?(Required)

Yes, I would like to use my health insurance

No, I would like to pay out of pocket

Health Insurance

If you would like to use health insurance for our social skills groups, please fill out the information in the section below.

Subscriber's Name

First Last

Insurance

Front of Insurance Card

Max. file size: 64 MB.

Back of Insurance Card

Max. file size: 64 MB.

Copy of ASD Diagnostic Report

Max. file size: 64 MB.

Comments and Questions

Please use this space for any questions, comments or concerns! We will reach out with a confirmation of enrollment.

Center Based Services

In-Home ABA Services

School Based ABA Services

Registration

ABA Therapy Registration Form

Health Insurance

Comments and Questions