Form – Autism Specific Services

Autism Specific Services (ABA) Form

  • Please complete the following information & submit online. You can also download this form from our website, fill out on your computer and print, scan and email to, or print and fax to 919-896-6443.

    * indicates required.

  • Client Information

  • Contact Information:

  • Insurance Information:

  • Primary:

  • Secondary
  • Reason for Referral/Primary Concerns about the Client:

  • During the intake process we will be requesting detailed information regarding your child’s history, current needs, and caregiver concerns. Please identify your top three concerns that you would like addressed during the first 6 months of treatment.
  • You will be hearing from us within 72 hours. At that time a member of Access Family Services will be requesting a copy of a signed diagnostic or psychological evaluation confirming a diagnosis of Autism Spectrum Disorder(F84.0).