Book Appointment | Behavioral Aid Solutions

Appointment Request

BOOK SESSION NOW

Booking an appointment or refer for services is simple using our online platform. By collecting your information online we are expediting this process and avoiding unnecessary delays. We will NEVER request for your Social Security information online or any virtual communication.

No one will be denied access to services due to inability to pay, and there is a discounted/sliding fee schedule available based on family size and income. To learn more about our Sliding Scale Discount Program click here.

Once the form is completed, hit the send button and one of our team members will get in touch with you.

Fields with a (*) are required.

Name *

Phone Number *

Email *

Address *

City *

Zip Code *

Date of Birth *

Gender *

Race *

Ethnicity *

Marital Status *

Parent / Guardian

Insurance Name * (Write Self Pay / Sliding Scale if applicable)

Insurance Member ID * (Write Self Pay / Sliding Scale if applicable)

Primary Care Physician * (Write N/A if applicable)

Psychiatrist * (Write N/A if applicable)

Requested Service Modality

Preferred Language *

Service Requested / Description

Referred by

Referral Phone Number

Referral email

School Name * (Write N/A if applicable)

School Grade

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone Number *

Click on the send button below once. You will receive an email confirmation. Make sure to also check your email's spam folder.

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