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info@heroesminds.com
Home
About
Services
Careers
Book Online
Contact
Home
About
Services
Careers
Book Online
Contact
Home
About
Services
Careers
Book Online
Contact
Home
About
Services
Careers
Book Online
Contact
281-547-8105
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appointment
book an appointment
Schedule your child’s ABA therapy session easily online. Choose a convenient time, and our team will confirm your appointment promptly.
Schedule Your Appointment
Easily schedule your child’s ABA therapy session online. Select a convenient time, and our team will confirm your appointment promptly.
Contact Information
Parent/Guardian First Name
Parent/Guardian Last Name
Primary Email
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Address - line 1
Address - line 2
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Child Information
First Name
Last Name
Birth Date
Gender
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Male
Female
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Prefer not to answer
Current Insurance
Insurance Benefits and Eligibility Release of Information
Yes
No
Does your child have a medical diagnosis of Autism?
Yes
No
How did you hear about us?
Select...
Web Search (Google or other)
Social Media
Referral from Primary Healthcare Provider
Referral from Diagnostic Evaluation Provider
Referral from Speech or OT Provider
Referral from Insurance Company / Insurance Website
Referral from another ABA Provider
Client Referral
Community Event
Employee Referral
Word of Mouth
ABA Grant Provider
Other
If "Other", please write in
Please list who referred you to Heroes Minds ABA and Autism Center
Referring Provider's Name
Optional Information
Insurance Subscriber's Name
Insurance Subscriber's Date of Birth
How does your child communicate?
Spoken Words
Sign Language
Use of a Communication Device
None of the Above
Does your child engage in any behaviors of concern?
Yes
No
Do you have any concerns regarding feeding?
Yes
No
Files
Diagnostic (Dx) Evaluation
Please ensure the report includes a recommendation for ABA therapy and an Autism diagnosis to prevent any processing delays for Heroes Minds ABA and Autism Center.
Insurance Card (Back)
Insurance Card (Front)
please call us at 281-547-8105 or email info@heroesminds.com
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