Forta Health

Summary

summarize Summary close

shopping_cart Cart close

Forta Client Intake

Congratulations, you have been pre-qualified for Forta's Virtual ABA! To finalize your enrollment, we need to gather a bit more information about you and your child and verify your insurance benefits. Please complete the form and schedule your intake call!

Parent Email *

Parent Full Name *

Parent Phone# *

Full Address *

123 Family St, Chicago, IL, 12345

Child Full Name *

Child Date of Birth *

Child Gender *

Male

Female

Which statement best describes your experience with ABA? *

We have yet to receive an ASD diagnosis, but want ABA

We have an ASD diagnosis and this is our first time seeking ABA

We received ABA in the past but no longer have access to it

We are currently receiving ABA, but seeking a new provider

What level of autism was diagnosed? *

Level 1

Level 2

Level 3

No ASD Diagnosis

Did not receive a Level

Name & Title of Diagnosing Clinician

This should be the name of the clinician who completed and signed your diagnosis report.

Name & Title of Primary Care Provider

How many hours per week are you and your child available for Virtual ABA Therapy? *

Would you be interested in learning more about grants & financial assistance programs? *

Yes

Could you tell us more about your situation and the specific services you are looking for?

Open ended for you to share more about your family, your situation, what you are hoping to achieve with Forta ABA and any questions you may have.

Forta Client Intake

Click Submit to finish.

This content is neither created nor endorsed by Formesign. Report abuse