ABC Behavioral Services

Charts and data visualization documents on a desk.

Child Referral Process

To refer a child for ABA therapy, please complete the form below. Our team will review the information and follow up with next steps.

Child Referral Request Form

Please provide as much detail as possible to help us evaluate and start the referral process promptly. Submissions are sent directly to our clinical team.

← Back

Thank you for your response. ✨

Parent / Guardian or Referring Provider Name

Email Address

Phone Number

Child’s Full Name

Child’s Date of Birth

Child’s Diagnosis (e.g. Autism Spectrum Disorder)

Insurance Provider

Insurance Member ID

Authorization Status

Additional Notes or Reason for Referral

Submit Referral