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Licini Inc ABA® Request Form

Thank you for your interest in our ABA therapy! Please fill out the form below to request to join our waitlist. Please be aware that we accept most insurances, but at this time we DO NOT ACCEPT MEDICAID. A member of our team will reach out to you with any additional information or questions.

Let's start with your personal details

Name of child/children needing ABA therapy?

Age of child/children?

What Insurance do you have?

*We do NOT take Medicaid*

Licini Inc ABA® Request Form

Let's start with your personal details

Name of child/children needing ABA therapy?

Age of child/children?

What Insurance do you have?

What are your main areas of concerns and what goals do you have for your child to accomplish?

What are your child's behaviors of concern?

Child/Children current diagnoses and medical conditions?

Do you have any questions for us, and is there anything you'd like us to know?

How did you hear about us?