Get Started

Ready to Begin the Enrollment Process?

Our in-house team handles the insurance processing for each family. We will work with you to coordinate the best combination of funding to ensure your child receives the services they need. Please fill out the following information to help us determine your coverage. Once we receive the information, a member of our team will reach out to you to discuss options.

Child's Name*
First Last
Gender*
- Male
- Female
Child's Date of Birth*
MM slash DD slash YYYY
Has your child received a diagnosis of Autism?*
- Yes
- No
Father's Name
First Last
Father's Date of Birth*
MM slash DD slash YYYY
Mother's Name
First Last
Mother's Date of Birth*
MM slash DD slash YYYY
Email*

What's the best email to reach you at?
Phone*
What's the best number to reach you at?
Address*
Street Address Address Line 2 City State ZIP Code
Primary Insurance*
Primary Insurance ID #*
Primary Policy Holder's Name
Secondary Insurance*
Secondary Insurance ID #*
Secondary Policy Holder's Name
Desired service?*
- Home-based ABA Therapy
- Center-based ABA Therapy
- Community-based ABA Therapy
- Speech Therapy
(Select all you would like to learn more about)
Additional Comments
How did you hear about us?