Contact Us

Contact our Support Office

Name

Date of Birth

Name of Parent

Relationship to Client*

Phone

Street Address

City,State,Zip

Diagnosis for Autism Spectrum Disorders?

Primary Health Insurance Company*

Insurance Member ID(for verification of benefits)"

Group ID

Name of Pediatrician

Employer (associated with primary health insurance)

Insurance Phone Number (on card)

Preferred Appointment Date and Time

Types of Therapy

ABA

Speech