Eligibility Verfication Form
Please complete the form with all the required details to serve you better.

Parent Details

Second Parent / Guardian (if applicable)

Patient Information

Subscriber Information

Insurance Information

Note: Copy of Medical Insurance Card need to be attached for insurance verification.

Medical Information

Note: In order to receive Applied Behavior Analysis (ABA) services, eligible individuals must have a valid ASD diagnosis. We require all pages of the comprehensive diagnostic report.
           Autism diagnoses is a must to qualify for Medical ABA insurance eligibility.

Preferred Time Slots

Please select your region and city to view the available timeslot.

Service Location

Referral Source

Available Hours Per Week

Please select the available hours per week for your treatment session.