Autism Services Referral Form

We are happy to accept referrals submitted through the form below. 

If you have any questions, please contact us at (319) 286-4545 

  • An autism diagnosis is required for ABA services. Services will not start until a diagnostic report or verification is provided. Please attach ABA documentation and a copy of insurance card, if applicable, in upload section below.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Providing an email address, if available, helps us connect you to needed services as efficiently as possible.
  • Recommended/Requested Services

  • Please include information about current symptoms, behaviors, functioning and trauma. Do these occur in the home, school, community, or across all settings?
  • Primary Insurance

    Insurance verification is required before appointment. While insurance information is not required as part of this form, providing it now will expedite the path to treatment.
  • Secondary Insurance (if applicable)

  • Drop files here or
    Accepted file types: jpg, pdf, png, gif.
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