CDC PLUS Inquiry Form

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Note: Before filling out this form you must contact your support coordinator and CDC rep to confirm you have funds available for a behavior Assessment ( $427.56 flat rate) and behavior therapy @ $100/hour in your CDC plus funds. A quick update will be needed to include this new service.

I am a solo provider and only provide level 1 funded BCBA services and do not offer BA (Behavior Assistant Services). All therapy is provided directly by a level 1 BCBA -solo rate / not agency rate .

Once you have confirmed you have funds in your budget please fill out this form and we will contact you via email
Hours of Operation M-F: 9 am-5 pm
Currently serving South west Broward: Miramar, Pembroke Pines , Weston , Hollywood, Davie, Cooper City.

Email *

Name of Person Filling out Form /Relationship to Client *

Waiver Support Coordinator (WSC) phone number and email *

Consumer 's Name *

How long have you been receiving CDC plus funding *

Home Phone/Cell Phone *

Can we text you at the phone number provided *

yes

Required

Address(es) of location of services to confirm you are within our service area. *

City *

zip code *

How did you hear about us? *

Please check all that apply: *

Consumer has had a behavior assessment has been conducted within the past year

Consumer has a current LRC approved behavior plan

Consumer has other cdc funded services (e.g day program, PCA, companion services,etc)

Consumer has received ABA Behavior therapy through other providers in the past

Consumer has received ABA therapy through insurance or private pay in the past

What Behavioral Challenges do you need help with? *

What days/times are you available for services? Please include details on any currently authorized number of hours consumer already has approved for behavior therapy services(if applicable). *

A copy of your responses will be emailed to the address you provided.

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