Parent's Name*

Address*

Contact Information*

Child's Name*

Child's Date of Birth*

Has Your Child Received a Diagnosis of Autism From a Licensed Physician?*

YesNo*

*If no, your child is not eligible for ABA Therapy Services at this time.

What Type of Service*

—Please choose an option—Clinic-Based ABA TherapyIn-Home ABA TherapyCommunity-Based ABA Therapy (e.g. daycare shadow, school shadow)

Insurance Carrier*

Preferred Clinic Location*

[text*]Mount Kisco, NY

Child's Availability*

Monday 9:00 AM - 12:00 PMMonday 12:00 PM - 3:00 PMTuesday 9:00 AM - 12:00 PMTuesday 12:00 PM - 3:00 PMWednesday 9:00 AM - 12:00 PMWednesday 12:00 PM - 3:00 PMThursday 9:00 AM - 12:00 PMThursday 12:00 PM - 3:00 PMFriday 9:00 AM - 12:00 PMFriday 12:00 PM - 3:00 PM

How did you hear about Connec-to-Talk?*

—Please choose an option—InstagramFacebookLinkedInGooglePhysician ReferralClient ReferralOther

Additional Information

Please Click Submit Once And Wait For Submission