Patient Information Forms            


***Please download and save the forms to your computer prior to filling out.

Please email forms to or fax to 352.600.3119

Beginning February 1st, 2017 all children with Medicaid eligibility must obtain prior approval from EQHealth for ABA Therapy (Behavior Analysis Services).

350 Acceptance Way

Clermont, FL 34711

  Office: 352.223.1999  

Fax: 352.600.3119

Servicing Lake and Orange Counties

If you're interested in being added to our waitlist, please download and complete the case history and patient information form. Email completed forms along with front and back copy of your health insurance card and a copy of the parent's drivers license.

Although the length of time it takes to get full approval for treatment varies with each insurance company,

it generally takes between 10 and 20 business days.