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Johns Creek and North & South Alpharetta locations

New Client Inquiry form

Our team specializes in ABA therapy for children up to age 10 diagnosed with Autism Spectrum Disorder. Fill out our form to start the process of getting ABA services for your child.

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Client Inquiry Form

"*" indicates required fields

About Your Child

What is your child's first name?*

First

What is your child's last name?*

Last

What is your child's date of birth?*

Our team specializes in ABA therapy for children up to the age of 10.

Which location are you interested in?*

If 'other' indicate your preferred location.

Has your child been diagnosed with Autism Spectrum Disorder within the past 3 years?*

If not, we may still be able to help support your child. We can help you find a psychologist or developmental pediatrician who can complete an autism evaluation.

Has your child received ABA within the last 6 months*

Who is your child's primary insurance provider?*

If you selected "other", who is your child's primary insurance provider?

What is your child's secondary insurance provider?*

If you selected "other", who is your child's secondary insurance provider?

How Can We Reach You?

We would love to chat with you. How can we get in touch?

What is your first name?*

First

What is your last name?*

Last

Your email address*

Email Address Confirm Email Address

Your phone #*

Zip Code*

ZIP / Postal Code

When would you like to start in our therapy program?*

How did you hear about us?*

Are you willing and able to commit to utilizing 90% or more of the medically appropriate level of care, as determined by your child's Behavior Analyst?*

Are you willing and able to commit to attend and consistently arrive on time to your child's scheduled therapy appointments? We require a minimum 95% attendance rate.*

Phone

This field is for validation purposes and should be left unchanged.