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Accelerate ABA

CENTER-BASED AUTISM SERVICES

Getting Started

If you are interested in pursuing services with Accelerate ABA please complete the form below and someone from the Accelerate team will reach out to you.

Please provide the following information(required)

My child is between ages 2-5 and I am interested in 1:1 teaching and developmental play group services

Parent/Guardian Name(s)(required)

Location(required)

Child Name(required)

Child date of birth (xx/xx/xxxx)(required)

Child gender(required)

Male Female

Has your child been diagnosed with autism spectrum disorder? This is a requirement for ABA services in New York State.(required)

Yes

Please list any additional diagnoses your child has

Who is your child's insurance provider? Please note, we do not accept Medicaid plans at this time.(required)

What is your child's insurance ID number?(required)

What is the provider contact phone number listed on the back of the insurance ID card?(required)

What skills are you hoping to address with ABA services? (Check all that apply)

Language & Communication

Social Interactions

Play skills

Self-help & independence (feeding, toileting, dressing)

Attending & focus

Other

Has your child ever participated in ABA services?(required)

Yes - currently Yes - in the past Never

Current/Former provider name and agency, if applicable

Does your child currently attend a preschool or daycare program?(required)

Yes No

Name of preschool or daycare program, if applicable

Parent/Guardian Phone Number(required)

Parent/ Guardian Email Address(required)

I understand that Accelerate ABA only provides center-based services and my child will need to be picked up/dropped off for services.(required)

How did you hear about us?

Physician referral

Name of Physician:

Facebook

Instagram

Internet Search

Other professional/agency

Name of other professional/agency:

Current client

Other:

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Hours & Info

7 Corporate Drive
Clifton Park, NY 12065

518-212-7559

info@accelerateaba.com

Mon-Fri: 8:00am-5:30pm

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7 Corporate Drive | Clifton Park, NY 12065
518-212-7559
© - Accelerate ABA

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