Welcome to RightWay ABA!

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

Thank you for choosing RightWay 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 (201) 540-8704 or email [email protected]

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Child Information

Child First Name *

Child Last Name *

Name Child is Known As

Date Of Birth *

Street Address *

State

City

Zip

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Caregiver Information

First Name *

Last Name *

Telephone (Cell): *

Email Address *

Relationship to Client *

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Primary Insurance *

Primary Insurance Card - Front *

Primary Insurance Card - Back *

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Secondary Insurance (If Applicable)

Secondary Insurance Card - Front

Secondary Insurance Card - Back

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Please upload all available documents related to the autism diagnosis. This may include diagnostic evaluations, assessment reports, or letters from a licensed provider.

Autism Diagnosis *

Some doctors include a recommendation for ABA therapy right inside the diagnostic report - usually a line that says something like 'ABA therapy is recommended' or 'the child would benefit from behavioral intervention.' If yours says something like that, you're all set.

If your report doesn't mention ABA therapy at all, your doctor will need to send us a separate referral. Not sure? Upload your report below and our team will check for you.

If No, please upload referral separately

Is a referral included in the diagnostic report

Yes

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What are your primary goals for ABA therapy? What would you most like to see change or improve for your child

Preferred Therapist Gender

Preferred Therapist Language

If Other, please specify language

Preferred Therapist Cultural Background

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Signature of Guardian

Clear

Printed Name

Date