A Preferred ABA Agency for your Child's Behavior Therapy

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Locations in Miami-Dade & Broward Counties, as Fully Enrolled Medicaid Providers

Please FILL the Form Below and a Representative from our Office may Contact you.

Full Name? (Nombre Completo) *

Contact Number (Numero de Telefono)

Email Address (Correo Electronico)

Are you the Parent/Guardian of a Child that's been Diagnosed with a Developmental Disability? (Su hijo/a ya fue diagnosticado/a por un especialista?) *

YES

What is your Child's Current Diagnoses? (Cual es el diagnostico de su hijo/a?) *

Is your Child currently Receiving Behavior Therapy? (Su hijo/a esta recibiendo Terapia actualmente?) *

YES

Do you PREFER Therapy for your Child at HOME or at SCHOOL? (Prefieres las terapias para su hijo/a en su casa o en la escuela?) *

HOME

SCHOOL

BOTH

Which COUNTY do you reside in? (En cual condado reside usted?) *

MIAMI-DADE COUNTY

BROWARD COUNTY

OTHER

Want a Representative from our office to Contact You? (Quisiera que un representante de nuestra oficina le contacte?) *

YES, Contact me Today.

NO, I Prefer Not to be Contacted.

Please CHECK BOXES Below if you Currently Have these Documents. (Por favor eliga los documentos que actualmente tiene debajo) *

Doctor's Referral (Referring to Behavior Therapy)

Letter of Medical Necessity (States Behavior Therapy's Medically Necessary)

CDE Report (Comprehensive Diagnostic Evaluation from Specialist)

Psychological Evaluation Report (Equivalent to CDE, Completed by Specialist)

IEP Report (Individualized Education Program Completed by School)

Behavior Assessment (Completed by BCBA)

Medicaid Insurance Card

Parent's Currently Dated Florida ID

None

Required

Residential ZIP CODE (Codigo Postal de donde vive actualmente)
*

reCAPTCHA - What is the correct answer? 5 - 2 + 6 - 3
*

THANK YOU for your Interest in SPECTRUM THERAPY CARE's Behavior Analysis Services. A representative from our office may contact you.

BY SUBMITTING THIS FORM, you fully consent and grant Spectrum Therapy Care and its Office Staff permission, to contact you via phone, text, email and/or social media. If you are contacted via social media, you also consent to be contacted within social media groups, as well as, send you link requests to join ABA Industry related groups and/or anything related to Behavior Analysis. In addition, you also agree that Spectrum Therapy Care and its Office Staff can use the contact information you provide today on the form, without limitations, in order to contact and send you important information about the ABA Industry and/or the services that you inquired for today. Shall you decide to withdraw this consent at anytime, you may send us an email specifying your request and a representative will remove you from our database immediately.

CONTACT US AT ANYTIME!

TOLL FREE 1(877)270-0707

Info@SpectrumTherapyCare.com.

FOLLOW US: Facebook, Instagram & Tiktok

@spectrumtherapycare #spectrumtherapycare

JOIN OUR TELEGRAM GROUP - PARENT SUPERHEROES

Visit SPECTRUM THERAPY CARE Site

You can also refer to our Privacy Policy on our website.

(Tambien se puede referir a la Poliza de Privacidad de nuestro sitio web)

(Tambien Hablamos Español)

Si usted necesita asistencia para poder entender el contenido que se ha publicado en este formulario antes de someterlo oficialmente, por favor contacte a nuestra oficina para poder ayudarlo/a. Si usted somete la informacion y la recibimos, le esta dando permiso a Spectrum Therapy Care y sus empleados que le pueda contactar sobre nuestro servicios.

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