GET STARTED

Enroll Your Child Today!

Complete the following form to enroll your child in our play-based ABA therapy. We will be in touch as soon as possible.

Getting to Know the Client

Who will be receiving our services

Client Name *

First

Last

Gender *

Date of Birth

Referred by *

Getting to Know the Family

Parent/guardian information

Parent/Guardian Name *

First

Last

Relationship to Client *

Marital Status *

Primary Email *

Street Address

City

State

Zip Code *

Cell Phone *

Home Phone *

Preferred Number

Cell Phone
Home Phone

Best Time to Call

The Paperwork

This is the last part! Please choose the best days and times for your appointments, and provide your funding information below.

Appointment Scheduling

Best Appointment Time *

Second Best Appointment Time *

Insurance Information

Choose your insurance provider below. Then take pictures of the front and back of your insurance card and upload them below.

Funding Source *

Our list of insurers continues to grow. If you don’t see your insurance company in the list above, please reach out to us, and we will discuss what we can do for your family.

Upload Front of Insurance Card

Click or drag a file to this area to upload.

Upload Back of Insurance Card

Click or drag a file to this area to upload.

Bot Test *