Beacon ABA Services is pleased to announce the opening of our new ABA centers in Chicopee, Milford, North Andover, and Rockland! Learn More

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Beacon Referral Form

Currently, Beacon Services is now accepting new clients over the age of 3 for our center-based services. Please complete the form below and the center director at your local center will contact you within 72 hours to discuss your child’s needs and availability.

"*" indicates required fields

Name of person completing form*

First Last

Contact email of person completing form*

Contact phone number of person completing form*

Relationship to Child*

Child's Information

Child's Name*

First Last

Child's Date of Birth*

MM slash DD slash YYYY

DPH number (for service coordinators only)

Child's Gender

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Family’s Primary Language

Is an interpreter required?

Yes

No

Has your child ever received a screening evaluation from Early Intervention?*

Yes

No

Unsure

Has your child ever received a diagnosis of autism from a psychologist or pediatrician before?*

Yes

No

Unsure

Parent/Guardian Information

Parent/Guardian Name*

First Last

Parent/Guardian Phone Number*

Parent/Guardian Address

Same as child's home address

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Email*

Enter Email Confirm Email

May we leave a message at the Parent/Guardian number provided?

Parent/Guardian #2

First Last

Parent/Guardian #2 Phone Number

Parent/Guardian #2 Address

Street Address Address Line 2 City State ZIP Code

Parent/Guardian #2 Email

Enter Email Confirm Email

May we leave a message at the Parent/Guardian #2 number provided?

Services of Interest

Services of Interest

Please check all that apply

Diagnostic Evaluation from a Licensed Psychologist

ABA Autism Treatment through Early Intervention

ABA Autism Treatment through Insurance - In-Home Services

ABA Autism Treatment through Insurance - Center-Based Services

Not Sure

Insurance

Insurance Carrier

** If your insurance is not listed, we are not in-network with that plan, please contact your insurance for an in-network provider **
Updated 8.2.2023

If Other, Please Specify Your Insurance Carrier

Insurance Member ID

Insurance Group ID

Insurance Phone Number

Image of the front of your insurance card

Accepted file types: pdf, jpg, png, Max. file size: 5 MB.

Image of the back of your insurance card

Accepted file types: pdf, jpg, png, Max. file size: 5 MB.

Secondary Insurance Information, if any

How did you hear about Beacon?*

For other, please specify

Verification

Phone

This field is for validation purposes and should be left unchanged.

Corporate Office

300 E Main Street #104
Milford, MA 01757
(508) 478-0207
Directions

Beacon ABA Services specializes in evidence-based treatment to young children

with Autism Spectrum Disorder (ASD).

Programs & Services

Early Childhood Diagnostic Services

In-Home Early Intensive Behavioral Intervention Services

Over the Age of 3 In-Home and Center-Based Applied Behavior Analysis Services

Resources

Patient Resources

Employee Access

Locations

North Andover, MA

North Dartmouth, MA

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