Application

Your child's journey starts here.

Thank you for considering Butterfly ABA. This quick form helps us understand your child and family so we can start building the right support. It only takes a few minutes — and once you're done, our team takes care of the rest.

🔒 Secure & confidential ⚡ Quick to complete 📄 We handle the insurance paperwork

What happens next

Here's what to expect

You submit this form.

Just a few minutes — that's all it takes.

We reach out.

Our team verifies your insurance and answers any questions.

A BCBA builds the plan.

They get to know your child and create a personalized plan.

Therapy begins.

And we're right there with you the whole way.

The form

Tell us about your family

📎 Along with this form, we'll need: a photo of the front & back of your insurance card and your child's ABA diagnostic report. You can attach them below — or send them later, no problem.

Client Information

Client full name *

Date of birth *

Gender

Full home address *

Medical

Medical diagnosis *

Diagnosed by

Diagnostician title

Pediatrician's name

Family Information

Parent/caregiver name *

Email *

Phone number *

Family status

Second parent/caregiver name (optional)

Second parent/caregiver email (optional)

Health Insurance

Primary insurance (company) *

Insured/subscriber name *

Subscriber date of birth

Insurance ID #

Secondary insurance (if any)

Insurance card — front & back (photo/scan)

ABA diagnostic report (PDF or photo)

Background Information

Your child's healthcare team

Primary care physician

Speech therapist

Occupational therapist

Physical therapist

Other providers

Current medications (medication, dosage, symptom treated, prescribed by)

Diagnosis other than autism? *

If yes, diagnosis & diagnostic code

Ever experienced or been diagnosed with a seizure disorder? *

Does your child have allergies? *

If yes to seizure disorder, please include a seizure action plan with your documents.

Existing medical concerns (check all that apply)

Hearing Vision Other

Does your child demonstrate any of the following behaviors? (check all that apply)

Other behaviors

Are there any aspects of your child's or family's well-being that you'd like us to focus on together?

School Information

Is your child currently attending school? *

Name of school

School contact name & phone

Current school schedule

Current school supports

Home Safety Checklist

Smoke detectors?

Carbon monoxide detectors?

Window guards?

Cleaning materials safely stored or out of reach?

Pets in the home?

Firearms in the home?

If yes — how are firearms secured in the home?

Household Members

Who lives in the home? (name, relationship, age — one per line)

Emergency Contacts

Please provide two contacts who are not the primary caregivers — people who are readily available and familiar with your child.

Contact 1 — name & relationship *

Contact 1 — phone & address *

Contact 2 — name & relationship

Contact 2 — phone & address

Secure & confidential. A member of our team will be in touch within one business day.

🦋

Thank you — we've got it!

A member of the Butterfly ABA team will reach out within one business day. In the meantime, if you'd like to talk sooner, call us at (908) 987-7304. We can't wait to meet your family.