Intake Form - Connect ABA and Therapy

Intake Form

Thank you for your interest in Connect. Please provide your insurance information below. Our goal is to make your entire experience working with Connect as pleasant and easy as possible.

Your Name

First name

Last name

Your email

Phone

Location

Zip Code

Child's Name

First name

Last name

Child's Date of Birth

I am interested in the following services
ABASpeech TherapyOccupational TherapyPhysical TherapyMultimedia Psychosocial GroupsDBT Groups

Does your child have an established diagnosis?

If Yes, what is the diagnosis?

Insurance Provider

Subscriber Name

First Name

Last Name

Identification Number

Upload scan of insurance card (front/reverse)

Additional Information

I give Connect ABA & Therapy consent to contact my insurance provider to obtain information regarding my coverage and benefits.

How did you hear about Connect?