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Acclaim Autism

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Forms

Medical Professionals:

  • Referral Form
  • IBHS Written Order Form

Existing Clients:

  • Authorization For Disclosure of Protected Health Information (PHI)
  • Authorization For Use and Disclosure of Patient Photographic and/or Video Images
  • Consent to Email Protected Health Information (PHI)
  • COVID-19 Form
  • Functional Behavior Assessment (FBA) Consent
  • Request to Amend Protected Health Information (PHI)
  • Secure Document Submission

Stay Informed


Jenkintown & Northeast Philadelphia,
101 Greenwood Ave,
Jenkintown, PA 19046

Southern California
2372 Morse Avenue, Suite 583
Irvine, CA 92614

West Chester,
419 N Franklin St, Suite 2,
West Chester PA 19380

Lancaster & Dauphin Counties &
342 N Queen St,
Lancaster, PA 17603

Administrative Office Address:
2929 Arch St, Suite 1700
Philadelphia PA 19104

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Acclaim Autism
  • Home
  • Services
    • ABA Therapy
    • School Support
    • Social Skills Groups
    • Summer & Holiday Camps
    • Telehealth
  • About Us
  • New Client Application
  • Careers
  • Blog
  • Locations
  • Help
    • Contact
    • FAQ
    • Resources
    • Forms
    • Secure Document Submission
    • Referral Form
    • COVID
    • Disclosures
  • Staff Login