Lakewood Basic Information Form | ABA & Behavioral Therapy for Autism

Parent/ Guardian's Name*
First Last
Email*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Primary Policy Holder*
First Last
Birthday of Primary Policy Holder*
MM slash DD slash YYYY
Client Name*
First Last
Client DOB*
MM slash DD slash YYYY
Client Social Security Number
Patient Diagnoses Code*
How did you hear about Connect Plus? We would personally like to thank them.*
Insurance Plan*
Upload a copy of the front and back of your insurance card*
Drop files here or
Max. file size: 256 MB.
*We participate with most insurance plans. We are not yet partnered with medicaid.
Do you have a Secondary Insurance Policy?*
Secondary Insurance Plan
Upload a copy of the front and back of your secondary insurance card
Drop files here or
Max. file size: 256 MB.
I acknowledge that Connect Plus Therapy might not be in-network with my insurance plan and hereby authorize Connect Plus Therapy to check eligibility for ABA benefits:*
Parent/ Guardian signature that the above information is true.*