Therapeutic Services PLLC

Outpatient Mental Health

This is the information that we need written in an ABA referral on referring provider letterhead (not Tricare):

  • Name of Patient
  • Date of Order
  • Patient Diagnosis of Autism Spectrum Disorder
  • DOB of Patient
  • Insurance Provider 
  • Contact Phone Number
  • "This is a referral for A New Leaf Therapeutic Services PLLC to provide Applied Behavior Analysis"
  • Signature of treating/overseeing provider
  • Printed name of treating/overseeing provider
  • NPI # of referring provider


Speech and Language

If you are a doctor or potential client and are looking for a form that is not on our website, please contact us! 

Referral Forms