Telehealth Registration Form | ABA & Behavioral Therapy for Autism

Intake Request For Telehealth Form

Telehealth consultations are available for both clients and non cpt clients. The fee for BCBA consultation is $120/hour Initial BCBA assessment will be approximately 60-120 minutes Follow up sessions will have a 30-minute minimum Please email eve@connectplustherapy.com for additional questions

Email*
Parent/Guardian*
First Last
Clients Name*
First Last
Clients Date of Birth*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Are you interested in becoming a Connect Plus Therapy Client?*
How did you hear about us?*