Welcome to National Behavioral Care
Please enjoy this short form to find out if you qualify for behavioral (ABA) Services
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What is your first name? *

 
What is your last name,  {{answer_28279767}}

 
{{answer_28279767}}, are you interested in behavioral services for a family member (son, daugther), or yourself?


 
Do you have health insurance? *

You may be covered by your workplace or a family member.


 
Which insurance company are you with, {{answer_28279767}}?

















 
Which insurance company is the person you are reaching us about covered by, {{answer_28279767}}?

















 
Which insurance company is {{answer_28279770}} covered by, {{answer_28279767}}?

















 
How old is your son or daughter? *

 
How old are you? *

Used to calculate coverage
 
How old is she/he?

 
Does your son or daughter have a diagnosis?


 
Do you have a diagnosis?


 
Does she/he have a diagnosis?


 
Now that we have the basics, it looks like you may be eligible for Behavioral Services. To get started, how should we contact you?


 
Now that we have the basics, it looks like they may be eligible for Behavioral Services. To get started, how should we contact you?


 
What is the best number to reach you at? *

Include area code
 
Is there anything else you would like to share?

Thank you.
Your information has been submitted successfully. An intake specialist will reach out to you in the next 48 hours
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