Refer a Patient | Forta Health ABA
Refer a Patient
Please use this form to refer a client to Forta's Virtual ABA program. We will review their information and be in touch with them to review their fit for our program.
See a list of approved insurances by state →
Referring Provider Information
- Practice/Clinic Name*
- Provider Name*
- Address*
- Phone*
- Fax
- Email*
Patient Information
- First Name*
- Last Name*
- Parent / Guardian First Name*
- Parent / Guardian Last Name*
- Date of Birth*
- City*
- State*
Select a State: Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District Of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming - Parent Phone*
- Parent Email*
Insurance Information
- Insurance Type
Select: Commercial, Medicaid/MCO - Insurance Company
Select one...
Referral Notification
- Has the Referred Patient been notified of Forta*
Select one... Yes, No - Preferred Language*
Select: English, Spanish, Other
Patient Diagnosis
- Child has a clinical diagnosis of Autism Spectrum Disorder (ASD) (ICD-10 F84.0, 299.0, or equivalent)*
Select one... Yes, No - Are you the diagnosing provider?*
Select one... Yes, No
Additional Notes
By checking this box, I agree that this is my electronic signature. Yes, I consent to electronic communication from Forta using the information I provided.
Privacy and accessibility: Notice of Privacy Practices · Accessibility Statement
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Have Questions? Let's Talk.
We understand that integrating a new referral partner into your practice requires trust and collaboration. Schedule a brief, no-obligation call with a Physician Liaison to discuss our clinical model, referral process, and how we can best support you and your patients.