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About Us
Our Services
Meet Our Team
Parent Resources
Career
Contact Us
Get Started
Step 1: Client Intake Form
Client Intake Form
* Indicates required fields
Child's First Name
Child's Last Name
Birthday
Does your child have an Autism Diagnosis within the last 3 years?
Yes
No
Does your child have an Autism Diagnosis?
Yes
No
Has your child received ABA services within the last 6 Months?
Yes
No
What is your Child's primary insurance provider
Aetna
Amerigroup
Anthem (Blue Cross Blue Shield)
Caresource
Cigna
Compsych
Georgia Medicaid
Optum/United Healthcare
Peachstate
Tricare
What is your child's secondary insurance provider
None
Aetna
Amerigroup
Anthem (Blue Cross Blue Shield)
Caresource
Cigna
Compsych
Georgia Medicaid
Optum/United Healthcare
Peachstate
Tricare
Parent First Name
Parent Last name
Insurance Subscribers Full Name
Insurance Subscribers DOB MM/DD/YY
Your Phone #
Your Email Address?
Zip Code
Are you willing and able to commit to attend and consistently arrive on time to your child's scheduled therapy appointments? We require a minimum 95% attendance rate.
Are you willing and able to commit to utilizing 90% or more of the medically appropriate level of care, as determined by your child's Behavior Analyst?
Service Location Request
Clinic-Based
In-Home
MDE School
Other School
How did you hear about us?
Insurance Card(S) ( Front & Back)
Submit
Step 2: Upload Required Documentation
Parent Name (Subscriber)
Child's Name
Autism Diagnostic Report
ABA Script from Doctor
IEP
Submit
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