Service Inquiry

Service Inquiry

Please complete this form to inquire about services. All information will be kept confidential.
Child Name

First NameLast Name
Child Age
Child Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Diagnosis
Address
Did your child previously receive ABA?
In-home service preferred schedule
How would you describe your child’s verbal abilities?
How would you describe your child’s problem behavior?
Guardian Name

First NameLast Name
Guardian Relationship
Guardian Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Guardian Contact Email
example@example.com
Insurance Company
List of paperwork for ABA
Thank you for your interest in our ABA services.

Before we proceed we will need the following documents.

1. Copy of assessment with autism diagnosis from developmental pediatrician, licensed psychologist and others.

2. Copy of health insurance front and back include primary and secondary insurance.

3. ABA referral from primary care physician (PCP) must be 2026.

Send the following documents to info@ascend-aba.com

We will verify your insurance coverage and documents first. Once everything is ready you can schedule the intake with our BCBA/ Clinical Director Cherry via Zoom or in-person in our Bronx or Queens office.

Schedule your intake with our office managers at 888-500-0230

Bronx - Mahjee

2040 McGraw Avenue, Bronx, NY 10472

Queens - Shifat

7226 Roosevelt Avenue, 2nd Floor, Roosevelt, NY 11372
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