Enrollment Form

Let’s Get Started

Thank you for your interest in Albright ABA! Please fill out the following preliminary questionnaire as completely as possible.

  • Psychologist Evaluation/ Autism Diagnosis
  • Referral for ABA Therapy / letter of medical necessity [from Primary care physician]
  • IEP Report
  • Photo of child’s insurance card [front and back]
Child’s insurance carrier*
What is your child’s diagnosis?*
Is your child currently enrolled in school?*
Does your child have a current IEP at school, if enrolled?*
Has your primary care physician written a letter of medical necessity / made a formal referral for ABA Therapy within the last year?*
Which problem behaviors does your child exhibit? (select all that apply)*
How frequently does your child engage in the challenging behaviors you identified?*
How would you describe your child’s expressive communication (select all that apply)?*
Has your child previously been in ABA therapy?*
Are you currently on a waitlist at another ABA company?*
Is your child currently receiving, or on a waitlist for, any other therapies? (if yes, select any that apply)*
What is your preferred method for an initial contact from us?*
File size limit of 10MB. You can upload PDF, doc, docx, txt, xls, xlsx, csv, jpeg, jpg, gif and png files.