Astra ABA Therapy

Astra ABA • North Carolina

What state do you live in? *

North Carolina

Other (we may not currently serve your area)

Child’s Full Name(s)

If you have multiple children, please separate each name with a comma.

How old is your child? *

Under 2

2–4

5–8

9–12

13–17

18–21

Does your child currently have an autism diagnosis? *

Yes

Recently evaluated

No

Not sure

Are you interested in getting started with ABA therapy services with Astra ABA?

Yes, I want to get started right away

I'd like to learn more about ABA therapy services first

I'm already receiving ABA services elsewhere

I'm not interested in ABA therapy

What insurance does your child have?

(Example: Medicaid, Aetna, Cigna, Blue Cross Blue Shield)

What is your child’s date of birth?

If you have multiple children, please separate each date of birth with a comma.

What is your Zip code? (this helps us know that we are reaching people in our area) *

What is your Full Name? *

What is your best phone number? *

What is your best email address? *

I agree to the terms & conditions provided by Astra ABA, and by providing my phone number, I agree to receive text messages from Astra ABA.