Services Inquiry Form (New)

Inquiry Form
Thank you for your interest in StarBright ABA, we look forward to connecting with you!
Contact Information

Telephone:(845) 320-2855• 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 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?
What is the reason for your inquiry?
If you require assistance, please call us at (845) 320-2855 or email us at info@starbrightaba.com

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