Skip to content
Facebook-f
Linkedin-in
Instagram
Youtube
Careers
Refer a Patient
Payment Portal
Call us today: 855.444.5664
Call Us
About Us
Close About Us
Open About Us
Our Mission, Vision & Values
Our Team
Locations
Close Locations
Open Locations
ABA Therapy locations
Colorado
Colorado Springs
Colorado Springs East
Connecticut
Hamden
New Haven
Norwich
Stamford
Florida
Boca Raton
Bradenton
Coral Gables
Cutler Bay
Ft. Lauderdale Metro
Jacksonville Metro
Kendale Lakes
Kendall
Miami Metro
Orange Park
Palm Bay Metro
Palm Beach
Sarasota Metro
Sunrise
Vero Beach
West Palm Beach
Yulee
Georgia
Saint Marys
Illinois
Barrington
Chicago Metro
Mokena
Naperville
Peoria Metro
Peru
St. Charles
Kansas
Overland Park
Kentucky
Bowling Green
Georgetown
Hebron
Lexington
Lexington West
Louisville
Louisville South
Mount Sterling
N. Kentucky Metro
Taylor Mill
Oklahoma
Oklahoma City
Tennessee
Jackson
Texas
Austin
Austin Metro
Bee Cave
Dallas Ft. Worth Metro
Frisco
Harker Heights
Killeen Metro
Round Rock
San Antonio
San Antonio Metro
Schertz
Southlake
Wisconsin
Madison
Verona
Mental Health locations
Kentucky
Bowling Green
Corbin
Fort Mitchell
Lexington
Louisville
Maysville
Find A Location
Near You!
Autism Services
Close Autism Services
Open Autism Services
ABA Therapy
In-Home ABA Therapy
In-School ABA Therapy
Mental Health Services
Close Mental Health Services
Open Mental Health Services
Mental Health Therapy
Waiver Services
Targeted Case Management
Resources
Close Resources
Open Resources
FAQ
What to Expect
Blog
News & Events
Contact
Close Contact
Open Contact
Contact
Intake Form
Find a Location
Get Started
Intake Form
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Name of Patient Receiving Services
*
Patient Receiving Services DOB
*
First Name
*
Last Name
*
DOB
*
Date of Birth
Guardian's Name
*
Guardian's First Name
*
Guardian's Last Name
*
Email
*
Phone
*
Address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Insurance Provider
United Healthcare
Blue Cross Blue Shield
Anthem
Aetna
Evernorth/Cigna
Tricare
Medicaid
Other
What service are you interested in?
*
ABA Therapy
Mental Health Services
Waiver Support Services
Targeted Case Management
How did you hear about us?
*
Online Search
Referred by Family/Friend
Referred by Doctor
Social Media
Insurance
Event
Other
SMS
By checking this box, I consent to receive SMS from Cultivate Behavioral Health & Education. Reply STOP to opt-out; Reply HELP for support; Message & data rates may apply; Messaging frequency may vary. See our
Privacy Policy.
Submit
Therapist Name
Therapist Designation
Therapist Bio
