Revive Behavioral Therapy Waitlist Form

Thank you for your interest in Revive Behavioral Therapy. Please complete the form below to be added to our waitlist for ABA services. This helps us better understand your child’s needs and match you with the right support as soon as space becomes available. If you have questions while filling out the form, feel free to reach out to our team—we’re here to help every step of the way.

Contact Information

Parent's First Name *

Parent's Last Name *

Phone *

Email *

Address *

Postal code *

City *

State *

Are you the Primary Caretaker? *

Yes

No

Preferred Method of Contact *

Phone Call

Text Message

Email

Client Information

Patient's First Name *

Patient's Last Name *

Patient's Date of Birth *

Referring Physician *

Services Currently Receiving

Occupational Therapy (OT)

Physical Therapy (PT)

Speech Therapy (ST)

Applied Behavior Analysis Therapy (ABA)

Other

Has your child had ABA before? *

Yes

No

If yes, then where?

Primary Diagnosis *

Autism Spectrum Disorder (Level 1)

Autism Spectrum Disorder (Level 2)

Autism Spectrum Disorder (Level 3)

Other Diagnosis (Optional)

Are you currently on any other waitlists? *

Yes

No

Briefly describe your child's behaviors. *

Service & Schedule Preferences

What services are you interested in? *

In-Home ABA

School-Based ABA

Community-Based ABA

If School Services are needed, please fill out.

Name of School
Address of School
Phone Number of School

Preferred Start Date *

Days/Times Available for Services (Ex. 9:00 am - 5:00 pm) *

Monday
Tuesday
Wednesday
Thursday
Friday

Are you open to virtual parent training ABA education support? *

Yes

No

Not Sure

Insurance & Payment

Primary Insurance Provider *

Secondary Insurance Provider (Optional)

Member I.D. Number *

Front of Insurance Card *

Back of Insurance Card *

Diagnostic Report (Autism Diagnosis) *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

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