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.
Autism Services Referral Form
Please include information about current symptoms, behaviors, functioning and trauma. Do these occur in the home, school, community, or across all settings?
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)
Accepted file types: jpg, pdf, png, gif, Max. file size: 256 MB.
Drop files here or