Enroll | ABA & Behavioral Therapy for Autism

Let's Get Started

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Step 1 of 5

Please select the Connect Plus Therapy location closest to you.

Connect Plus Location*

Unfortunately, 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 ZIP Code

Client Name*

First Last

Client DOB*

Client Gender*

Patient Diagnoses Code*

The diagnostic code for autism is F84.0.

Primary Language Spoken at Home*

Hidden

Client Social Security Number*

Primary Policy Holder*

First Last

Birthday of Primary Policy Holder*

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 ?*

Front of Your Secondary Insurance Card - Upload an Image

Accepted file types: jpg, png, jpeg, Max. file size: 16 MB.

Back of Your Secondary Insurance Card - Upload an Image

Accepted 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:*

Services

What types of service are you interested in?*

How did you hear about Connect Plus?

Parent/ Guardian signature that the above information is true.*