Refer a Patient | My Team ABA

Start a referral

Takes about two minutes. Choose the option that fits you.

This is a secure referral form. The details you share are treated as protected health information (PHI) and used only to coordinate care, verify benefits, and contact you.

I'm a referring provider I'm a parent / family

About you & your practice

Contact name *Required.

Practice / organization *Required.

Work email *Enter a valid email.

Phone *Required.

Practice addressOptional — helps us coordinate records.

About you

Your name *Required.

Your email address *Enter a valid email.

Your phone number *Required.

State *Required.

Your ZIP code *Required.

Your child

Child's full name *Required.

Child's date of birth *Required.

InsuranceOptional — we verify coverage for you.

Reason for referralOptional.

Patient information

Patient / child full name *Required.

Child's age

State *Required.

InsuranceOptional — we verify coverage for you.

Reason for referral

Tell us a little more *Please share only the information needed to begin intake.Required.

Release of information

Sharing records? Download our ROI authorization form, complete & sign it, then attach it here.

Download ROI form Attach completed ROINo file selected

Optional · PDF or image · max 10 MB

Encrypted and confidential — reviewed within one business day.

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

Thank you — your referral is in.

Our intake team will review the details and reach out within one business day.

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