Intake Form

Please fill out our intake form below and we will be in touch with you as soon as possible to discuss your next steps.

    Parent's Name*


    Contact Information*

    Child's Name*

    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*

    Insurance Carrier*

    Preferred Clinic Location*


    Child's Availability*

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

    Additional Information

    Please Click Submit Once And Wait For Submission