Let's Get Started "*" indicates required fields Please select the Connect Plus Therapy location closest to you.Connect Plus Location*Select Nearest LocationCherry Hill, NJNorthfield, NJLakewood, NJUnfortunately, at this time, we cannot accept new clients in our Bala Cynwyd, PA location. Parent / Guardian's Name* First Last Email* Phone*Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Client Name* First Last Client DOB* MM slash DD slash YYYY Client Gender*MaleFemalePatient Diagnoses Code* The diagnostic code for autism is F84.0.Primary Language Spoken at Home* HiddenClient Social Security Number* Primary Policy Holder* First Last Birthday of Primary Policy Holder* MM slash DD slash YYYY Your Insurance Member ID#* Front of Your Insurance Card - Upload an Image*Accepted file types: jpg, png, jpeg, Max. file size: 25 MB.Back of Your Insurance Card - Upload an Image*Accepted file types: jpg, png, jpeg, Max. file size: 25 MB.Do you have a Secondary Insurance Policy ?*SelectYesNoFront of Your Secondary Insurance Card - Upload an ImageAccepted file types: jpg, png, jpeg, Max. file size: 25 MB.Back of Your Secondary Insurance Card - Upload an ImageAccepted file types: jpg, png, jpeg, Max. file size: 25 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:* ServicesWhat types of service are you interested in?* ABA at Our Center ABA in Your Home Early Childhood Program Adult Day Program Summer Camp Private School / Day Care Other How did you hear about Connect Plus? Parent/ Guardian signature that the above information is true.* Reset signature Signature locked. Reset to sign again
