Sensory Kids and Social Minds Inquiry
158 Newark Ave and 441 Jersey Ave, Jersey City, NJ. Occupational Therapy (OT), Speech-Lanugage Therapy (SLP) and Applied Behavior Analysis (ABA)
Thank you for inquiring about our OT, SLP and ABA services at Sensory Kids & Social Minds in Jersey City, NJ
We are OUT OF NETWORK providers for OT and SLP services. We do not have a contract with Medicaid/Horizon NJ Health at this time. We are IN NETWORK for ABA services with most insurance carriers. If interested in ABA services, all children with our practice must receive OT and/or SLP services alongside ABA therapy using our relationship-based DIR Floortime approach through an interdisciplinary model.
Child's Name
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First Name
Last Name
Child's Birth Date
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Month
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Day
Year
Date
Parent 1 Name
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First Name
Last Name
Parent 2 Name
First Name
Last Name
Parent 1 Email
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example@example.com
Parent 2 Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent 1 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent 2 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What services are you seeking? Reminder if you are interested in ABA services, all children with our practice must receive OT and/or Speech-Language Therapy in conjunction with ABA therapy for our collaborative team approach.
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Occupational Therapy
Speech Therapy
ABA Therapy
Why are you seeking services?
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Does your child have a medical diagnosis or script for OT/ST/ABA from your doctor?
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Yes
No
If so, what is the diagnosis/diagnosis code?
Does your child attend school?
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Yes
No
If so, what grade and where do they go to school?
What is the best day and time to reach you for a phone call with one of our supervisors?
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Morning hours (9-11 am)
Lunch time hours (11 am-1 pm)
Afternoon hours (1-4 pm)
Evening hours (4-6 pm)
Other
Explain "other" days/times or more specific times that work for you if necessary
Insurance Company Name:
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Aetna
Horizon
United Healthcare
Cigna
No insurance/ private pay
Other
Explain "other" if necessary:
Do you have out of network Benefits? Reminder we are OUT OF NETWORK for OT and Speech-Language Therapy. We are IN NETWORK with most private insurance for ABA Therapy. We do not have a contract with Horizon NJ Health/Medicaid at this time
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Yes
No
I Don't Know
N/A (if private pay)
Thank you for filling out this form! A supervisor will be in contact with you within the next few days!
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