First Name *

Parent/Guardian

Last Name *

Parent/Guardian

Email *

Phone *

Best method of contact:

Email
Phone
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Child’s age:

Does your child have a diagnosis of autism? *

Yes

No

Does your child have a referral for ABA services? *

Yes

No

Coverage: *

Tricare Prime
Tricare Select/Retired
ChampsVA
Blue Cross & Blue Shield
Cigna
Aetna
Private Pay
Other
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Please provide any additional information about your child’s need for ABA services: *

We are presently in network with Tricare (TriWest Health Alliance), Aetna, and we are currently in process to be in network with Blue Cross & Blue Shield, Cigna, and Texas Medicaid. Please note that all coverage plans we presently work with require an autism diagnosis in order for the child to access services.

By submitting this form and signing up for texts, you consent to receive text messages related to scheduling an appointment and information related ABA Comprehensive Services to the number and email provided.