Autism/ABA Client Wait List
Please fill out our HIPAA compliant wait list form. Our Support Team can contact you when we have openings. Diagnostic Evaluations for children suspected of having ASD currently have a 6 month waiting period. Please speak with us first before completing the waitlist for ABA services. Provider availability varies based on location.
Name of Person Completing the Form
*
First Name
Last Name
Name of Prospective Client
*
First Name
Last Name
Date of Birth or Prospective Client
*
-
Month
-
Day
Year
Date of Birth of Person who is seeking services
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Service Requested
*
ABA Therapy for Autism
ADOS-2 Testing (ASD Diagnosis)
Have you received ABA Services from another company within the past 6 months?
*
Yes
No
Insurance
*
BCBS of NJ- Commercial Plans
Horizon NJHealth/NJFamily Care
Aetna-Commercial Plans
Aetna Better Health
Optum/United Health Plans/UHC
Wellcare
Amerigroup
Other
Enter Insurance ID#
*
Do you have a report diagnosing your child with autism (F84.0)
*
YES
NO
Briefly Describe why you are seeking ABA services
*
Ex: violent tantrums, physical aggression, verbal aggression, speech & language issues, poor self-help skills, limited socialization.
Availability for Service Delivery
*
(Days & Times: Mon-Friday 4-8; Saturday after 12pm)
Front Copy of Insurance Card
Browse Files
Cancel
of
Back Copy of Insurance Card
Browse Files
Cancel
of
Report with Autism Diagnosis
Browse Files
Cancel
of
Submit
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