Welcome to Rising Above ABA!

Your first step toward getting your child the support they deserve.

Thank you for choosing Rising Above ABA. This application takes about 5-10 minutes and gives our team what we need to verify your insurance and begin your child's intake. Once submitted, our intake team will review your information and reach out within 1-2 business days with next steps.

Need help? Call or text us at 781-294-3414 or email [email protected].

Child's Information

Child First Name *

Child Last Name *

Child Preferred Name (If Different)

Date Of Birth *

Address

Street Address *

City *

State *

Postal Code *

Child's Preferred Language *

What school does your child attend?

Type of school

What days/times is your child in school?

Is your child receiving any other therapies?

Does your child currently have an IEP? *

Please Upload the IEP Plan

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Contact Information

Primary Guardian

Guardian 1 Full Name *

Relationship to Child *

Primary Phone Number *

Secondary Phone Number

Email Address *

Preferred Method of Contact *

Text/SMS

Phone Call

All of the above

Best Times to Contact *

Morning

Midday

Afternoon

Evening

Scheduling & Availability

Guardian 2 Full Name

Guardian 2 Relationship to Child

Guardian 2 Primary Phone Number

Guardian 2 Email Address

Guardian 2 Preferred Method of Contact

Who should be the primary contact for Rising Above communications? *

Scheduling & Availability

Emergency Contact Name

Emergency Relationship to Child

Emergency Contact Phone Number

Emergency Contact Address

Insurance Information

Primary Insurance Carrier *

Primary Member ID# *

Primary Group #

Primary Insurance Card - Front *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Primary Insurance Card - Back *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Insurance Information

Secondary Insurance Carrier

Secondary Member ID

Secondary Group #

Secondary Insurance Card - Front

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Secondary Insurance Card - Back

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Medical & Diagnosis Information

Primary Care Provider *

Date of Last Physical

Diagnosing Provider *

Date of Diagnosis *

Upload Diagnostic Report *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Is a referral/prescription included in the diagnostic report? *

upload 'Please upload referral or prescription separately (if you have one)

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Upload Most Recent Physical

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Does your child have any safety concerns we should know about before services begin (e.g., wandering/elopement, aggression, self-injury, medical conditions requiring monitoring)? *

Scheduling & Availability

We ask for at least 18 hours of weekly availability so we can build a consistent and effective therapy schedule. Our clinical team will recommend hours based on your child's assessment; most children we serve benefit from 15-40 hours per week. Wider availability helps us match your child with staff faster. To support stability, availability changes may be submitted once every 3 months.

Weekday Preferred Times (Please note, times do not have to be exact. We are just getting an idea of when you are looking for services) *

Morning (8am-12pm)

Afternoon (12pm-3pm)

Evening (3pm-7pm)

Weekend - Preferred Times for Services *

Specific Times of Availability *

Preferred Location for Services *

Summer Availability

Service Logistics & Interests

I am interested in learning about transportation support (PT-1) *

I can provide adequate parking at the therapy location (within a 5-minute walk) *

Other programming I am interested in

Consent for Insurance Verification & Authorization *

I authorize Rising Above ABA to contact my insurance carrier to verify eligibility and benefits and to request prior authorizations necessary for the delivery of ABA services." This consent lives here (not on the Acknowledgement form) because intake verifies insurance before that form is sent.

Accuracy Attestation *

I certify that the information provided in this application is accurate to the best of my knowledge.

Signature of Guardian *

Clear

Printed Name *

Date Today *