Request Services for Your Child
Fill out a request for services form

To explore possible enrollment in any of our ABA programs, complete the Request for Services form and submit it to our office. This allows our clinical staff to quickly gather information about your child so we can efficiently answer your questions and give you a recommendation on which services should be provided to meet your child’s individualized needs.

Please fill out this form in its entirety. Upon receipt of your completed form, we will contact you within one to two weeks to further discuss our services and program philosophy.


Autism Partnership
200 Marina Drive
Seal Beach, Ca 90740
(562) 431-9293
Fax (562) 431-8386
Tell us about your family
years old
Service information
Primary Insurance information
Secondary Insurance information

If none, type “n/a”

Current Services that are being Provided

ABA at home or school, Speech, OT, etc.

School Information
Additional information