Your Child's Independence Is Our Mission

Please Fill Out the Intake Form:

Parent's Name

Parent's Phone Number

Address

Email *

Child's Full Name

Child's Date of Birth

Child's Age

Child's Gender

Has your child been diagnosed with Autism?

Insurance Carrier

Policy Number

Group Number

Policy Holder

Is the child currently receiving ABA services?

Yes

No

Current ABA Provider

Location Preferred:

Home

School

Preferred Session Time:

Morning

Afternoon

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Prevail ABA Therapy

407-593-1101

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