Service Inquiry Form
Behavior-Cise ABA, (applied behavior analysis), is delighted that you are interested in allowing us to service your family! BehaviorCise provides behavior therapy within the community and our clients' homes. Our approach of community based natural environment teaching allows our clients and families to stretch and tone behaviors to achieve their desired emotional physique!!  

After reviewing our services, if you are interested in securing ABA with us, please take a quick moment to email m.totty@behaviorcise.com a copy of the front and back of your insurance card, the front and back of the insurance policy holder's identification card and a copy of your child's Medical Diagnosis of Autism, (conducted at an approved autism evaluation center).

Please complete this new client inquiry form that allows us to learn about your awesome kiddo :)   
Sign in to Google to save your progress. Learn more
Email *
Desired ABA service location, (daycare, school, home, extracurricular / recreational activities etc.)
Parent / Gaurdian Name (s)
Person to be serviced name and birthdate
What behaviors do you want to gain or stop ?
Does the person being serviced have a medical diagnosis of Autism, that was completed via an evaluation from an AAEC, (approved autism evaluation center)?  A copy of the AAEC will need to be submitted to your insurance for service authorization. *
Contact Phone Number and Email
Name of Insurance and Insurance ID #
How did you discover BehaviorCise 
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Behavior-Cise ABA Professional Services, LLC.

Does this form look suspicious? Report

Google Forms