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.

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*

Parent Phone*

Parent Email*

Insurance Type*

Insurance Company*

Has the Referred Patient been notified of Forta*

Preferred Language*

Patient Diagnosis

Child has a clinical diagnosis of Autism Spectrum Disorder (ASD) (ICD-10 F84.0, 299.0, or equivalent)*

Are you the diagnosing provider?*

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.

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

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.

Book a Call with a Physician Liaison