What is your child's first name?
*
What is your child's last name?
*
What is your child's date of birth?
*
What city do you live in?
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Has your child been diagnosed with Autism Spectrum Disorder within the past 3 years?
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Yes
No
Unsure
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Has your child received ABA within the last 6 months?
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Yes
No
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Who is your child's primary insurance provider?
*
Blue Cross Blue Shield
Cigna / Evernoth
DMBA
HMHI-BHN
Medicaid of Utah
Optum/ United Healthcare
Select Health
None
Other
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What is your child's secondary insurance provider?
*
Blue Cross Blue Sheild
Cigna / Evernorth
DMBA
BHN
Medicaid of Utah
Optum / United Healthcare
N/A
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Submitter's First Name
*
Submitter's Last Name
*
Submitter's relationship to client
*
Email
*
Phone
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Postal code
*
When would you like to start in our therapy program?
*
How did you hear about us?
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Are you willing and able to commit to attend and consistently arrive on time to your child's scheduled therapy appointments? We require a minimum 90% attendance rate
*
Yes
No
I have questions
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