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Eligibility Check
Upon completing this form we will contact you within 24 hours to discuss services.
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* Indicates required question
Your Name
*
Your answer
Phone #
*
Your answer
E-mail
*
Your answer
Child's Name
*
Your answer
Child's DOB
*
MM
/
DD
/
YYYY
Child's Insurance
*
Aetna
Cigna
Florida Blue (BCBS)
Medicaid (all plans)
Tricare
Other:
Child's Insurance #
*
Your answer
where will services be provided?
*
Indicate locations where behavior is of concern.
Home
school
daycare
other
Required
Full Home Address
*
Your answer
School Address
*
If you would like services provided at school enter the school name, otherwise enter n/a
Your answer
Availability
*
Mark all times the child is available for services
8am - 10am
10am - 12pm
12pm - 2pm
2pm - 4pm
4pm - 6pm
6pm - 8pm
Required
Language service can be provided in
*
English
Spanish
Other:
Required
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