2.00 Parent Step 1 (initial info)
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What brings you here today?
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I am looking to receive ABA Therapy for my child.
I am looking to switch ABA Therapy providers within Florida
I am looking to have a consult with Dr. Josh Levine, Ph.D., BCBA, LBA. I am not looking to get ABA Therapy for my child at this time. I'm just exploring the ABA Therapy option for my child and have questions about it.
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Parent first name
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Parent last name
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Child's name
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Primary Email
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Does your child live and go to school in either Orange or Osceola county?
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Does your child have a diagnosis?
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Please select your insurance carrier
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Medicaid-CMS, or Aetna, or Cigna
Other (e.g., Medicaid-Sunshine Health, Blue Cross Blue Shield, Tricare)
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Primary Phone
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Can we text you at this number?
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What is your relationship to the child?
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Mother
Father
Grandparent
Guardian
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Address Line 1
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City
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State / Province
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ZIP / Postal Code
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Child's first name
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Child's last name
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Child's date of birth
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Child's gender
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Female
Male
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Does you family plan to move out of Orange or Osceola county in the next 6-12 months?
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Unsure
Please upload a picture of the front and back of your insurance card
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Do you have secondary insurance?
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What specific concerns or challenges are you experiencing with your child’s development that led you to look into ABA therapy today?
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Please share how you heard about us!
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Google search
Friend
From child's school
Came across your website
Through your social media profiles
Other
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Is there anything else you'd like to share?
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Submission Received! Thank you!
Be on the lookout for an email with next steps!
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