Voyage Behavior's Contact Us Form

Here is the full-text version of our Contact Us Form. Should you need help filling out this form, please call the office at (321) 486 - 9243, and someone will assist you.

Please fill in the following information, and someone will get back to you within five business days.

Caregiver(s) Information

o Primary Parent/Guardian Name: 

o Primary Parent/Guardian Phone Number(s):

o Primary Parent/Guardian Email Address:

Basic Client Information

o The Client’s Full Name: 

o Client's Date of Birth MM/DD/YYYY:

Insurance Information

(Please scan a copy or upload a clear picture of the front and back of your child’s insurance card(s).)

o Insurance Company’s Name:

o Insured’s Name:

o Insurance ID Number

o Insurance Group Number:

o Provider Phone Number(s): (This is usually the provider's pre-certification or prior authorization number(s).)

List of documents that you will need to start ABA Therapy:

o Do you have an ABA Referral? If so, what is the date of the ABA Referral: (The referral for ABA must be dated within less than one (1) calendar year from today for most insurance plans.)

o When is the Date(s) of Initial Diagnosis(es):

o What is the Diagnosis(es):

o Was Comprehensive Neuropsychological Evaluation Report (confirms initial diagnosis):

o (Optional) Does your child have an Individualized Education Program (IEP) or 504 Plan? If so, when was it last updated?:

o (Optional) Any other pertinent documents or reports of medical history pertaining to behavioral and educational accommodation(s); and or any incident(s) involving a crisis plan, law enforcement, and or psychological hospitalizations resulting in the client being Baker Acted or arrested.

Please describe the main reason(s) that you are seeking ABA therapy for your child: 

Here are a few examples that may help you answer this question.

o Please tell us in a few sentences why you are seeking ABA services for your child. 

o Have they ever received ABA Therapy before? 

o Are there any social skills, behavioral goals, or daily living skills you or your child would like help with? 

o Are you willing to participate in parent training along with your child's ABA therapy?

Please only attach a copy of the front and back of the insurance card(s). 

Once we have established that we are in-network providers for your child, we will begin the intake process and send you a link to a HIPAA-secured folder to upload all the other information.