Family, integrity, measurable progress, and independence. (727)-643-7695Call to schedule a consultation today! In-Network Insurances Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name of Person Completing this form *FirstLastName of child *FirstLastChild's Date of Birth *MM/DD/YYYYAddress *House/Unit Number, Street, City, Zip CodeInsurance ProviderCMS, Medicaid, Tricare, BCBS, Aetna, Cigna, United, etcChild's Insurance Member ID Number *Referred by (Name)N/A, MD, Developmental Specialist, NeurologistDiagnosisAutism Spectrum DisorderOppositional Defiant DisorderADHDCurrent Behavioral Concerns:AggressionSelf Injurious BehaviorProperty DestructionEloping (running out of building, room, vehicle, etc)Mouthing/PICAFloppingScreaming/yellingTantrumsDefiance or problems w/ authorityOtherCheck the unsafe behaviors that you have been experiencing?My child is experiencing:Communication DelaysDevelopmental DelaysDifficulty making friendsIsolated sociallyBullyingLack of coping skillsProblems at schoolPotty training difficultiesLack of safety awarenessSensory concernsWhat delays have you been seeing or skills you'd like more teaching with?Documentation RequiredComprehensive Diagnostic EvaluationABA Referral LetterInsurance CardCheck the documents that you have?Any Additional Concerns?Submit