Language
English (US)
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Parent Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Child's First Name
*
Child's Age
*
Please Select
1
2
3
4
5
6
7
Has your child received a formal autism diagnosis?
*
Please Select
Yes
No
Evaluation in process / waiting for evaluation
Insurance
*
Please Select
Aetna
Cigna
FL Blue
BCBS [out of state]
CMS
Please note: At this time, we do not accept any Medicaid plans, except CMS. (Aetna Better Health, Community Care Plan, Humana, Sunshine Simply Medicaid etc or United Healthcare)
How did you hear about Pivotal Achievements?
Please Select
Web Search (Google)
Doctor/Neuro Referral
Insurance Company Directory
Social Media (Facebook, Instagram)
SLP/OT Referral
Friend/Family
Child's Daycare/School
Referred by another ABA provider
We'd love to hear more about your child! Please feel free to share any additional details.
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