waitlist

Parent/Caregiver/Adult Client Name *

First Name

Last Name

Child's Name

First Name

Last Name

Client Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

What services are you interested in?

Assent-Based Applied Behavior Analysis

Acceptance and Commitment Training (ACT)

Professional Mentoring

Parent Coaching Sessions

Support for Pathological Demand Avoidance (PDA)

In-person services

Virtual services

What state are you located in?

New Jersey

Pennsylvania

Other

Availability

I am (or my child is) available for sessions:

Weekday mornings (9am-12pm)

Weekday early afternoons (12pm-3pm)

Weekday afterschool (3pm-5pm)

Weekday evenings (5pm-7pm)

Other/not sure yet

Check all that apply

Formal Autism Diagnosis (required to use insurance)

Self-diagnosed or suspected Autism

ADHD or ADD (diagnosed or suspected)

PDA

What insurance provider do you have?

Horizon BCBS NJ

Independence Blue Cross

Aetna

Cigna

UnitedHealthcare

ComPsych

Quest

Other

Amerihealth

I won't be using insurance