Bright Light

Please use this form to submit a referral for services or to get in contact with a member of our team.

If you are interested in learning more, please contact us at 800-244-4691

Requested ABA Service Information

Bright Light Service State*

North Carolina

Georgia

South Carolina

Reason for Referral*

Person to be Served Information

First Name*

Last Name*

Date of Birth*

Gender

Female

Male

Other

Unknown

Primary Contact Phone*

Phone

Primary Email Address*

Address*

Please include building/Apt #’s if applicable

City*

State/Province/Region*

Select

Postal/Zip Code*

Language(s) Spoken by Person Being Served

Referral Source Information

Referring Agency Business Name (if applicable)

Referral Source Name*

(person ie. Referring Physician name)

Referral Source Contact Phone Number*

Phone

Insurance Information

Primary Insurance Name*

Primary Insurance Policy #*

Do you have Secondary Insurance?*

Yes

No

Secondary Insurance Name

Secondary Insurance Policy #

Parent/Legal Guardian Information

First Name

Last Name

Relationship

Mother

Father

Spouse

Legal Guardian/Custodian

Child

Foster Parent

Other

Please describe relationship to Person to be Served*

Primary Phone #

Phone

Service Information

Please attach below: Diagnostic Evaluation and Copy of Insurance Card (front and back)*

Drag and drop files here or

How did you hear about us?*

Social Media

Ads

Flyer

Website

Google Search

Other

Social Media

Facebook

Instagram

Psychology Today

Ads

Facebook

Instagram

Psychology Today

How did you hear about us?

Example: Advertising leaflet/flyer, word of mouth, existing or previous person being served, community event/open house, or something else!

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