Private Pay Intake Request

Private Pay Intake Form

Consultations are available for non-CPT clients The fee for BCBA consultation is $120/hour Behavioral Technician Services $60/hour Initial BCBA assessment will be approximately 60-120 minutes. Follow up sessions with BT and BCBA 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
Credit Card Holder*
Credit Card Number*
Expiration Date*
CVV #*
Billing Address if different from above
Street Address Address Line 2 City State Postal Code
How did you hear about us?*
Consent*
Connect Plus Therapy is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below to say how you would like us to contact you: *
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Private Pay Intake Form

Info@connectplustherapy.com

856-827-7630