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Please use the referral form below for children that already have a documented Autism Spectrum Disorder (F.84) diagnosis.

APPLIED BEHAVIOR ANALYSIS (ABA THERAPY)

Questions? Call Us at (718) 871-4464 option 1

Practice Name(Required)

First Last

Provider Name(Required)

First Last

Provider Phone Number

Provider Fax Number

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient Name(Required)

First Last

Date of Birth(Required)

Guardian Name

First Last

Primary Phone Number

Guardian Email Address

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insurance Carrier (attach card front and back if available below)

Member ID

Requested Services:

Applied Behavior Analysis (ABA Therapy)

Diagnosis and/or ICD 10 Code (e.g., Autism Spectrum Disorder F84.0)

Diagnosis Date

Insurance Card (Front and Back)

Max. file size: 50 MB.

Office Notes and Psychological Evaluation Documentation

Max. file size: 50 MB.