Serving Children with Autism & Learning Differences from Early Childhood Through Adolescence

Application for Home and Center Based
Hourly ABA Therapies

Incomplete or illegible applications and /or applications submitted without an attached diagnosis report and referral letter cannot be processed.

Hourly Therapy Options

(Please select all that apply AND include estimated hours and times preferred per week) *minimum of 4 hours / week required

Client Information

Funding Information

Primary Insurance Information

Secondary Insurance Information

Additonal Information

Responsible Party



Emergency contact

Patient Release & Acknowledgement