Request ABA Services at ABA Therapy Solutions by form, phone or email

Who we serve

ABA Therapy Solutions provides behavioral therapy for children and young adults with autism and other related disabilities.

ABA Therapy Solutions clinics, provide ABA therapy. Services are for toddlers through age 5 who are diagnosed with autism and other related developmental disabilities.

You can also request ABA services for In-Home, or In-Community for toddlers through young adults. Our Board-Certified Behavior Analysts and Registered Behavior Technicians will accommodate services in a convenient location for you.

Return to ABA Therapy Solutions Home Page

Request ABA Services by Form

Fill out the form below and click “Submit”

Request ABA Service by Phone or Email

Contact Janine our Intake Coordinator by phone ext. 104 or email.

Request ABA Services-Janine Testa, RBT and Intake Coordinator

Fill out the form below to request services

Child's Information
Date:*
Month
Day
Year
Child's Name:*
First Last
Child's Date of Birth:*
MM slash DD slash YYYY
Child's Gender:*
How did you hear about us?*
- Doctor/Medical Facility
- Teacher/School
- Friend/Relative
- Social Media
- Search Engine
Child's School Name:
Child's Grade:
Availability-AM
Focused treatment is typically 15-30 hours per week in the home. Indicate the time frames that you and your child are available for services in the home. Use the + sign for additional rows if availability is split throughout the day.
Mon Tue Wed Thu Fri Sat Sun
Availability-PM
Focused treatment is typically 15-30 hours per week in the home. Indicate the time frames that you and your child are available for services in the home. Use the + sign for additional rows if availability is split throughout the afternoon/evening.
Mon Tue Wed Thu Fri Sat Sun
Other psychological tests, results, diagnostic evaluations, reports, etc.
Drop files here or

Accepted file types: jpg, pdf, png, Max. file size: 25 MB.
Concerns about your child:
Parent/Guardian Information
If parents are separated or divorced information for both must be provided.
Parent/Guardian 1's Name:*
First Last
Parent/Guardian 1's Email Address:*
Enter Email Confirm Email
Parent/Guardian 1's Phone Number*
Parent/Guardian 1:*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian 2's Name:
First Last
Parent/Guardian 2's Phone Number:
Parent/Guardian 2's Email Address:
Enter Email Confirm Email
Parent/Guardian 2 Address (If different than Parent 1):
Street Address Address Line 2 City State ZIP Code
Primary Insurance Information
Primary Insurance Company:*
- Aetna
- BlueCross BlueShield
- Cigna
- Medicaid
- Meritain Health
- TriCare
- United Healthcare
Primary Insurance Phone Number:*
Subscriber Name:*
First Last
Subscriber's Date of Birth:*
Month
Day
Year
Member ID Number:*
Group Number/ID:
Copy of Primary Insurance Card (Front & Back)
Max. file size: 100 MB.
Secondary Insurance Information
Secondary Insurance Company:
- Aetna
- BlueCross BlueShield
- Cigna
- Medicaid
- Meritain Health
- TriCare
- United Healthcare
Secondary Insurance Phone Number:
Subscriber Name:
First Last
Subscriber's Date of Birth:
Month
Day
Year
Member ID Number:
Group Number/ID:
Copy of Secondary Insurance Card (Front & Back)
Drop files here or

Accepted file types: jpg, pdf, png, Max. file size: 25 MB.
Consent
Do we have permission to contact your insurance company?*
- Yes
- No
Consent
I agree to the privacy policy.