• New Patient Intake Form

  • Part I: Patient and Family Information

  •  / /
    Pick a Date
  •  -
  • Part II: Diagnosing Information.

    ** Regrettably, we will be unable to move forward with your application at this time unless you have a referral/prescription for Applied Behavior Analysis with a diagnosis of Autism Spectrum Disorder AND a full evaluation by a qualified specialist with a diagnosis of Autism Spectrum Disorder and recommendations for Applied Behavior Analysis **
  • Click here to upload
    Cancelof
  • Part III:Primary Insurance Information

  •  / /
    Pick a Date
  • Browse Files
    Cancelof
  • Part IV:Secondary Insurance Information

    Only use this section if your child has 2 entirely independent insurance policies. DO NOT just submit your primary policy information again. Select "none" if this does not apply to your child
  •  / /
    Pick a Date
  • Browse Files
    Cancelof
  • Should be Empty: