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MAKE AN APPOINTMENT

We will review the information you provided and get in touch with you as soon as possible via email.

Child & Insurance

Child's name *

DOB *

Insurance name *

Insurance ID

My child is enrolled in Step Up

YesNo

If Yes, Student ID

Contact Information

Address *

City *

State *

Zip Code *

Email *

Phone Number *

By selecting this option, you agree to receive text messages from ABA Therapy of St. Lucie Inc. The number of messages may vary, and standard message and data charges could apply. Your phone number will only be used for SMS communications and will not be sold or shared with any third parties or affiliates for marketing. For help, text HELP to 772-327-1731. To stop receiving messages at any time, reply STOP.

Diagnosis & Clinical Documentation

Child's diagnosis (if applicable)

I have all clinical documentation from neurologist/psychologist

YesNo

Letter of medical necessity

YesNo

Dr referral for ABA services

YesNo

Copy of testing used by neurologist to establish diagnosis

YesNo

Report from psychologist

YesNo

My child is transferring from another agency

YesNo

If yes, I have a discharge letter

YesNo

Service Preferences

I prefer services at

Center School Daycare I don't know

I need

Full time service Part time services (in combination with school or daycare)

My child needs

Speech therapy Occupational therapy

I’m looking for services

In the morning Afternoon All day

My child is enrolled in

Public school Private school Daycare Home

My child is in grade

Other Therapy

My child is currently receiving

ST OT PT Feeding therapy

Review, Consent & Signature

Parent / Legal Guardian Full Name *

Additional comments

Electronic Signature *

I certify that the information provided is true and accurate to the best of my knowledge, and I consent to be contacted regarding this ABA application.

I agree and authorize this electronic submission.

Thank you.

Your ABA application has been sent successfully.

ABA Therapy of St Lucie

* Behavioral Therapy

Bilingual Key Therapy

* Speech Therapy

* Occupational Therapy

Hours of Operation

Monday – Friday 8:00am-7:00pm
Saturdays 8:00am-4:00pm