Provider Referrals for ABA Therapy

If you are a parent or guardian, please click here to get started.

Referring providers can submit referrals via fax to (409) 299-9460 or the referral form below. For faxed referrals, please include the patient’s insurance information, medical diagnosis, and medical records.

Please use the following form to refer a patient for ABA services.

Child's Details

Your Child's First name

Your Child's Last name

Their Birthday

Gender

Parent/Guardian Details

Parent/Guardian First Name

Parent/Guardian Last Name

Email address

Mobile number

Location of interest

Service type

Other Details

Referring Provider

Insurance Provider

Service Needed

ABA Therapy Diagnostic Evaluation

Please include requested documents below. We look forward to speaking with you soon!

Diagnostic Report

Insurance card

By submitting this form, you agree to be contacted by phone, email or text and that any associated call may be recorded for quality and training purposes. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.