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Confidential Client Information

Please fill out the form below to start your intake process. Once we receive this form, we will begin to verify your insurance information and will contact you via email to gain more information about your child and which of our services are of interest to you.


We do our best to ensure that the insurance benefits we relay to you are correct. However, Spectrum of Hope is not responsible for any errors or omissions conveyed to us by your insurance carrier. PLEASE BE AWARE THAT INFORMATION WE RELAY FROM YOUR INSURANCE COMPANY DOES NOT GUARANTEE COVERAGE.


NOTICE: Medicare/Medicaid does NOT cover ABA services in the state of Texas.
AVISO: Medicare/Medicaid NO cubre los servicios de ABA en el estadio de Texas.

  • Client Information

  • Date Format: MM slash DD slash YYYY
  • Family Information

  • Service Request - Click all that apply

  • Insurance Information

  • Date Format: MM slash DD slash YYYY