Child's Name
Date of Birth
Location ClevelandColumbus
Location In-CenterIn-homeIn-home & In-centerIn Child's DaycareNot Sure
Relationship of Contact to Child
Your email
Address
Insurance
Please SelectSelect oneSelect oneSelect one
Does the child already have an autism diagnosis?
YesNoNot Sure
If yes, what was the name of the facility and/or doctor who diagnosed them?
Does the child attend school? If so, what days and hours?
What days an times are you available for therapy?
Any other information you would like to share with us about your child Type here...
How did you hear about On Target ABA?
Please upload your insurance card here, or email it to [email protected].
If you have the child's autism evaluation report, please upload it here:
