If you are in need of more information we can be reached by phone at (267) 576-8818 or by email at operations@adapt-connect.comPlease have your insurance card(s) ready in order to complete the intake form below CLICK HERE TO GET STARTED! Intake Form Caregiver Information Please provide us with your contact details! Mother's Name * First Name Last Name Mother's Phone number * (###) ### #### Mother's Email * Father's Name * Father's Phone Number Father's Email Address of where you would want ABA services to occur * Address 1 Address 2 City State/Province Zip/Postal Code Country Time Frame in Which you would be available for ABA sessions * 8am-11am 11:30-2:30pm 3pm-6pm How did you here about us? * Are you currently receiving ABA services through another agency? If so, who? * Child Information Please tell us about your child Child's Name * First Name Last Name Check all that apply * Child is diagnosed with an Autism Spectrum Disorder Child is under the age 6 You are the child's legal guardian You live with the child The child has a prescription for ABA from their doctor The child has had a Psychological Evaluation within the last year Child's Date of Birth * Does your child attend school? if so what school and where is it located? * What are some of the reasons you are seeking ABA services? * Insurance Coverage Tell us about your insurance providers so that we may better understand your ABA benefits. Do you have insurance? * Yes, private insurance only Yes, both private insurance and medical assistance Yes, medical assistance only No, currently without insurance Your Primary Insurance Provider Enter your child's member ID # Your Secondary Insurance Provider (if applicable) Enter your child's member ID # Someone from the Adaptive Connections Team will respond to your inquiry in no more than 72 hours. Thank you!
