Submit Intake Form
Thank you for your interest in ChanceLight® Behavioral Health, Therapy and Education! To get started, please complete the below intake form and we will respond to you within one business day of receiving.
If you prefer, you may also call our intake line at (888) 227-7212, fax us at (615) 645-7625, or email us at firstname.lastname@example.org.
The information you provide to ChanceLight® is private and secure, and ChanceLight® will never share your personal information with third parties.
What you can expect during the Intake Process:
- Fill out the below intake form and attach all applicable documentation, if able (the upload option is located at the bottom of the form). Applicable documentation includes:
- If seeking ABA services, a psychological assessment or other evaluation from a licensed physician which reflects a diagnosis of autism and a prescription for ABA
- If seeking Speech Therapy or Occupational Therapy, the recommending scripts
- Copy of your insurance card (front and back) for any service
- You will be contacted by one of our Family Support Specialists who will assist you through the intake process, including verification of eligibility and benefit coverage.
Once your insurance is verified, your local team of ABA specialists will be contacting you to schedule an Initial Assessment at a clinic nearest you.