Preferred clinical location * - Select -SLC, UT locationOrem, UT locationLayton, UT locationRancho Cucamonga, CA locationSan Diego, CA locationVentura, CA locationCharlotte, NC locationConcord, NC location Type of Service(s) Needed * Psychological Evaluation Applied Behavioral Analysis Speech Therapy Occupational Therapy Individual/Group/Family Therapy Does client have an autism spectrum disorder diagnosis? (Insurances will not cover ABA therapy without a diagnosis.) Full name of person(s) completing this form * Email * Address * Phone Number * Client's Birthdate * Client's Name (if different from person completing form) If client is a minor, do you have legal custody? Insurance Name * Insurance ID * Policy Holder Name and Date of Birth * Why are you seeking Services? * ABA ONLY need fill in the availibiliy questions below. Monday Availability (What EXACT times can your child be consistently available for therapy? Tuesday Availability Thursday Availability Wednesday Availability Friday Availability Saturday Availability Sunday Availability After submission, you should hear from our Intake Department within two business days.