Patient Intake

Complete the form to get started with House of Hearts ABA Therapy.

Complete the form below to get started

Get Started

About your Child

First name

Last name

Date of Birth

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

State

Guardian Information Page

Short answer

Phone

Relationship to Child

Father

Mother

Other

Address

Diagnostic Information

Information about who evaluated / diagnosed your child.

Has your child been formally diagnosed with Autism by a doctor (MD, PHD,PSYD, etc)

Yes

Diagnosis Documentation

Doctor Referral and/or Comprehensive Evaluation/Assessment

Additional Documents

Pediatrician Information

Insurance Information

Insurance Provider

Insurance Group Number

Insurance card front

Insurance card back

What locations are you interested in ABA services for:

School

Community

Home

Short answer

By checking this box, I agree to receive Account Notifications and Customer Care SMS messages regarding appointment reminders, updates, and account inquiries from House of Hearts ABA at the phone number provided above. The SMS frequency may vary. Data rates may apply. Text HELP to (305) 209-3144) for assistance. Reply STOP to opt out of receiving SMS Messages Privacy Policy and Terms & Conditions.

Phone: (305)-209-3144
Fax: (305)-703-4994

Patient Intake

Complete the form to get started with House of Hearts ABA Therapy.

Complete the form below to get started

Get Started

About your Child

Guardian Information Page

Diagnostic Information

Pediatrician Information

Insurance Information

By providing your phone number, you agree to receive text messages from House of Hearts ABA . Message and data rates may apply. Reply STOP to opt-out.

About

Services

Careers

Brochure

Locations

Insurance

Blog

Meet the team