Services Inquiry Form (New)

Inquiry Form
See If We're a Good Fit!

Thank you for your interest in StarBright ABA to help you meet the needs of your child! Please note that although this does not guarantee enrollment, this is the first step. With the information below, we can see if our services and availability will be a good fit based on your child's needs, insurance, and schedule. We will contact you within a couple of business days to discuss. We look forward to connecting with you!
Contact Information

Telephone: 845-863-5208 • www.StarBrightaba.com • 118 River Road, Suite 14 Harriman, NY 10926
Client Information
Child's Name*

First NameLast Name
Child's Age*
Primary Caregiver Information
Primary Caregiver Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

Availability

Insurance Carrier
Insurance Provider*
If 'Other', please specify
Insurance ID
Provider Phone Number on Insurance Card
Please enter a valid phone number.
Insurance Card Front
Insurance Card Back
Does your child have an Autism Spectrum Disorder (ASD) diagnosis?*

YesNo
Reason for Inquiry
Current Behavioral Concerns (select all that apply)

Aggression to self (SIB)Aggression to othersInflexible routinesSelf-stimulatory behaviorsProperty destructionOther behaviors that interfere with your child's daily routines
Current Needed Support with Activities of Daily Living (select all that apply)

BathingDressingToiletingFeedingMorning RoutinesBedtime Routines
How does your child express his/her needs (i.e., vocal, gesture, cry)?
How does your child respond to requests?
How did you hear about us?
Any other questions or information you have for us?
IMPORTANT: Before we can verify your coverage with your insurance company, we need a copy of the front and back of your insurance card. Please scan or snap a picture of both sides and submit them in this form or to info@starbrightaba.com. If you require assistance, please call us at 845-863-5208 or email us.

Privacy Disclaimer: StarbrightAba will never sell your information to any third party person we are committed to protecting your personal information and your right to privacy.
Please verify that you are human*
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Inquiry Form