Contact Us!
Thank you for your interest in Reset Behavior! Please complete the form below to request ABA services and join our current waitlist. Our clinic currently provides ABA therapy Monday through Thursday from 7:45 AM to 6:30 PM. Please note that submitting this form does not guarantee immediate placement or enrollment in services.
Select your preferred location:
*
In Clinic: W. Charleston Location
In Home: General Las Vegas
In Home: North Las Vegas
In Home: East Las Vegas
In Home: Henderson
Person Completing This Form
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Language/ Idioma Preferido
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Full Name
*
First Name
Last Name
Has the client been formally diagnosed with Autism Spectrum Disorder (ASD)?
Please Select
Yes
No
Currently undergoing an evaluation
Diagnosis is pending
Unsure
A medical diagnosis completed by a physician, psychologist, or other qualified diagnosing provider is required. An IEP or school eligibility classification does not count as a formal medical diagnosis.
Client's Gender
*
Female
Male
Date of Birth
*
-
Month
-
Day
Year
Date
What services are you interested in?
*
ABA Therapy Services
Social Skills Classes
Behavior Support, Family Training, and/or Home Intervention Plans
Special Education Advocacy
ADOS-2 Assessment
Assessment (Tricare Specific, Outcome Measures, Functional Behavior Assessment/FBA)
Schedule a Community Training
Other
Would you like to be added to our waitlist for ABA therapy services?
*
Please Select
Yes, please add me to the waitlist.
I should already be on the waitlist.
Please remove me from the waitlist.
Not Applicable
Please select all available time blocks you are available for therapy.
*
7:45 AM – 3:15 PM
7:45 AM – 2:45 PM
7:45 AM – 2:00 PM
4:00 PM – 6:30 PM
3:30 PM – 6:30 PM
2:45 PM – 6:30 PM
Please select the day(s) your child is available. (Select All That Apply)
*
Available Monday-Thursday
Monday
Tuesday
Wednesday
Thursday
Please select your preferred therapy location:
*
In-Clinic
In-Home
Hybrid (In-Clinic and In-Home)
Flexible (Either/Or)
N/A
Primary Insurance
*
Secondary Insurance
How did you hear about us?
*
Melissa Kenyon, M.Ed., BCBA, LBA
Leapfrog ABA LV1
FEAT
Dr. Ezugha
Dr. Gaspar
Pediatric
OneCare
Insurance
Employee
Client
Other
How did you hear about us?
*
File Upload - Please upload the front and back of the insurance card and any available autism diagnosis, psychological evaluation, or referral documents.
*
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