Consultation

Your child’s journey toward growth, independence, and lifelong skills starts here.

Fill out this brief form, and a member of our care team will contact you within one business day to discuss your child’s needs and next steps.

Parent or Guardian Name

Email Address (For follow-up communication)

Phone Number (We’ll only contact you regarding your inquiry)

Child’s Name

Child’s Date of Birth:

Insurance Information

Primary Insurance Provider (e.g., Blue Cross Blue Shield, United Healthcare, Aetna, Cigna, etc.)

Insurance Member ID (optional) (If available — helps us verify benefits faster)

Do you have secondary insurance?

Yes No

Preferred Service Type

Upload Front Picture of Insurance Card

Upload Back Picture of Insurance Card

Preferred Days / Times for Sessions (Select all that apply)

Weekdays Evenings Weekends

How Can We Support Your Family? “Tell us a little about your child’s strengths, challenges, or what you’re hoping to work on through ABA Therapy.”

I understand that this form is for general inquiry purposes only. A Skills for Life ABA team member will contact me to discuss services, verify insurance benefits, and confirm eligibility