Enrollment Form

New Client Eligibility Form

Initial Client and Insurance Information Form
(Fields marked with * are required.)

Date of birth

Parent/Guardian Date Of Birth

Subscriber Date Of Birth

Back of Insurance Card

Click or drag a file to this area to upload.*

Autism Diagnosis Report

Click or drag a file to this area to upload.*

Front of Insurance Card

Click or drag a file to this area to upload.*

IEP, if applicable

Click or drag a file to this area to upload.*

Doctor Referral or Prescription for ABA

Click or drag a file to this area to upload.*