Intake Form
Parent/Guardian's First Name
*
Parent/Guardian's Last Name
*
Child's Full Name
*
Child's Date of birth
*
Gender
*
Phone
*
Email
*
What state do you live in?
*
Indiana
Tennessee
Georgia
Virginia
North Carolina
Other
Address
*
Street Address
City
State
Country
Enter your country
Postal Code
Does your child have an Autism Diagnosis?
*
Primary Insurance Name
*
Secondary Insurance Name
Insurance Subscriber/Policyholder's Full Name and Date of Birth (if different then the child's information)
Is your child currently receiving ABA Therapy by another provider or has your child received any direct ABA therapy OR assessments from another provider within the last year?
*
Pediatrician Information (Name, Email, Phone, etc.)
*
Availability for services
*
Monday
Tuesday
Wednesday
Thursday
Friday
Weekends
Desired service hours (During the week)
*
Morning (9am - 12pm)
Mid- Day (12-3p)
Evening hours (3-6p)
Anytime
Preferred location of services
Home
Center
School
Daycare
Other
Front of Insurance Card(s)
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
Back of Insurance Card(s)
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
Autism Diagnosis Report
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
Referral for ABA
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
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