For Healthcare Providers

Physician Referral Form

Refer a patient for ABA therapy services. Only child information is required.

Step 1 of 4Physician Info

Referring Physician Information

All fields in this section are optional

Physician Name

NPI Number

Practice/Clinic Name

Phone

Fax Number

🔒 All information is encrypted and HIPAA-compliant

We typically respond within 4 hours

👋 Hi! Ready to start your child's ABA therapy journey? Fill out this quick form and we'll reach out within 4 hours.

No Waitlist NH Medicaid Accepted

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