Please fill out our intake form below and we will be in touch with you as soon as possible to discuss your next steps.
Child's Date of Birth*
Has Your Child Received a Diagnosis of Autism From a Licensed Physician?*
*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)
Preferred Clinic Location*
Mount Kisco, NY
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
Please Click Submit Once And Wait For Submission