Skip to content
Welcome to Autism Celebrations
Call Us Now
(385) 245-2151
Mail Us Now
info@autismcelebrations.com
We Provide Services in
Weber, Davis and Salt Lake Counties
Facebook
Twitter
Youtube
Home
About Us
Services
Contact Us
Careers
Home
About Us
Services
Contact Us
Careers
Schedule Intake
Schedule Intake
Schedule Intake
(385) 245-2151
info@autismcelebrations.com
Weber, Davis and Salt Lake Counties
Home
About Us
Services
Contact Us
Careers
Home
About Us
Services
Contact Us
Careers
Schedule Intake
Schedule Intake
Fill out the form below and we will be in touch shortly.
Name
(Required)
First
Last
Caregiver Email
(Required)
Caregiver Phone
Insurance
(Required)
Please Select One
Aetna
Anthem
Cigna
DMBA
Molina
Magellan
Other BCBS
Regence BCBS
SelectHealth
UMR
University of Utah
United Healthcare
Utah Medicaid
WISE
Other (Please list)
Please list other insurance provider
(Required)
Service County
Davis County
Weber County
Salt Lake County
Other
Preferred Service Location (City)
Number of Patients
1
2
3
Name (Patient 1)
First
Last
Date of Birth
MM slash DD slash YYYY
Autism Diagnosis
Yes
No
Availability
Mornings
Afternoons
Mid-Day
Name (Patient 1)
First
Last
Date of Birth
MM slash DD slash YYYY
Autism Diagnosis
Yes
No
Availability
Mornings
Afternoons
Mid-Day
Name (Patient 2)
First
Last
Date of Birth
MM slash DD slash YYYY
Autism Diagnosis
Yes
No
Availability
Mornings
Afternoons
Mid-Day
Name (Patient 1)
First
Last
Date of Birth
MM slash DD slash YYYY
Autism Diagnosis
Yes
No
Availability
Mornings
Afternoons
Mid-Day
Name (Patient 2)
First
Last
Date of Birth
MM slash DD slash YYYY
Autism Diagnosis
Yes
No
Availability
Mornings
Afternoons
Mid-Day
Name (Patient 3)
First
Last
Date of Birth
MM slash DD slash YYYY
Autism Diagnosis
Yes
No
Upload Diagnostic Report
Max. file size: 256 MB.
Upload Insurance Card Front
Max. file size: 256 MB.
Upload Insurance Card BACK
Max. file size: 256 MB.
Availability
(Required)
Mornings
Afternoons
Mid-Day
Consent
Check this box to
Opt-in
to accept text/SMS messages in accordance with Autism Celebrations
Privacy Policy/Terms of Use