Let's Get Started "*" indicates required fieldsStep 1 of 520%Please select the Connect Plus Therapy location closest to you.Connect Plus Location*Select Nearest LocationCherry Hill, NJBala Cynwyd, PALakewood, NJNorthfield, NJUnfortunately, at this time, we are unable to accept new clients in our Bala Cynwyd, PA location.If you need help finding another agency to provide in-network services, please call the customer service number on the back of your insurance card.We sincerely regret that we are not able to provide you and your family with services, and hope that we will be able to serve you in the future.Parent / Guardian's Name* First Last Email* Phone*Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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: 16 MB.Back of Your Insurance Card - Upload an Image*Accepted file types: jpg, png, jpeg, Max. file size: 16 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: 16 MB.Back of Your Secondary Insurance Card - Upload an ImageAccepted file types: jpg, png, jpeg, Max. file size: 16 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 OtherHow did you hear about Connect Plus?Parent/ Guardian signature that the above information is true.*