ABA therapy appointment booking

for children with autism spectrum disorder

If you you wish to know if ABA therapies are an option for your child with autism, please fill the form below. Please don't omit any requested data, since all the information is necessary to attend your case properly. Once you have submitted all the information in the form, we will be communicating with you as soon as possible.

BOOK APPOINTMENT

Child's Name *

Child's Lastname *

Child's Birthdate *

DD/MM/YYYY

Child's gender *

Child's dominant language *

Child's tutor *

Tutor relationship to child *

Your Email *

Your Phone Number *

Your Postal Address *

Has your child been dignosed with autism? *

Yes

Is your child currently in any therapy? *

Yes

What treatment or therapy are you particularly interested for your child? *

Would you be interested in a social skills group for your child? *

HEALTH INSURANCE PROVIDER INFORMATION

Please select your type of insurance or payment method *

Medicaid

Commercial insurance

Direct pay

Health Insurance provider name

Health insurance membership ID

Main insurance cardholder name

Insurance cardholder birthdate

DD/MM/YYYY

Phone for corroborating insurance information

First Name

CALL US

(786)360-2655

BOOK APPOINTMENT