Get Help Request for Services If you would like to request services for your child, please fill out the form below., and we will get in touch with you soon. Please be advised that this service request form does NOT guarantee services. Service Request "*" indicates required fields Child's InformationChild's Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent's Name* First Last Phone*Email* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance InformationPrimary Insurance ProviderInsurance ID NumberMedicaid Number (if applicable)Policy Holder's Name First Last Policy Holder's Date of Birth Month Day Year Secondary Insurance ProviderDoes your insurance cover ABA therapy? Yes No Does your child have a referral for ABA? Yes No Does your child have a completed DSM-5 checklist? Yes No Even though your insurance does not cover ABA therapy, would you still like services? Yes No Requested Center-Based ServicesDesired WeekdaysCheck all that apply Monday Tuesday Wednesday Thursday Friday Desired TimeCheck all that apply Flexible 8am - 10am 10am - Noon 12:30pm - 2:30pm 2:30pm - 4:30pm Are there any current restriction to your child’s schedule that can NOT be changed? Yes No What days/times are those activities? (e.g. school, speech, OT, naptime, etc.)Has your child received ABA Previously? Yes No How many hours per week? Months? Years?Is your child receiving special education and related services? Yes No Are you interested in receiving assistance with your child's IEP? Yes No Do you have any comments and/or questions for us?PhoneThis field is for validation purposes and should be left unchanged.