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ABA Services
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Serving Children with Autism & Learning Differences from Early Childhood Through Adolescence

Getting Started

Application for Home and Center Based
Hourly ABA Therapies

Incomplete or illegible applications and /or applications submitted without an attached diagnosis report and referral letter cannot be processed.

How did you hear about us? (must select one)

Doctor referral

Brochure

Facebook

Internet

Insurance referral

Bright Feats Catalogue

CARD

Flyer

Provide The Name Of The Referring Doctor

Provide The Location Where The Brochure Was Received

Hourly Therapy Options

(Please select all that apply AND include estimated hours and times preferred per week) *minimum of 4 hours / week required

Hourly Therapy Options

IN HOME

AT CHILDS SCHOOL / DAYCARE

ON SITE AT OUR LONGWOOD LOCATION

Number of hours per week In Home

Days & Times In Home

Number of hours per week At School / Daycare

Days & Times At School / Daycare

Number of hours per week At Our Longwood Location

Days & Times At Our Longwood Location

Client Information

Last Name

First Name

Address Line 1

Address Line 2

City

State

Zip Code

Age

Date of Birth

Sex

Male

Female

Social Security Number

Primary diagnosis

Date diagnosed

Diagnosing physician

Age at diagnosis

Secondary diagnosis

Date diagnosed

Diagnosing physician

Age at diagnosis

Current school attending (put "N/A" if not attending)

Funding Information

Funding source(s) for therapy (select all that apply/ attach documentation):

Gardiner(step-up)

VPK/SIS

Health insurance

Private pay

Other

Annual Funding Amount

Funding Amount

ID Number

Must attach approval letter

Choose File

Must Attach Comprehensive Diagnostic Report

Choose File

Must Attach Physician Referral

Choose File

Must Attach Front Insurance Card

Choose File

Must Attach Back Insurance Card

Choose File

Must attach award letter

Choose File

Must attach ID card image

Choose File

Primary Insurance Information

Insurance company

Policy holder name

Date Of Birth

Policy number

Group number

Phone number for providers

Secondary Insurance Information

Insurance company

Policy holder name

Date Of Birth

Policy number

Group number

Phone number for providers

Additonal Information

Peanut allergy?

Yes

No

Does child have an epi-pen?

Yes

No

Other Allergies?

Yes

No

If yes, please list

Currently taking medication?

Yes

No

If yes, please list

Current / previous therapies tried?

Yes

No

If yes, please list

How does child communicate? (check all that apply)

Verbalizations

PECS

Pointing

Gesturing

Nonverbal

Sign Language

Other

Toilet trained (Check one)

Yes, fully

Yes, Partially

Not toilet trained

Please Explain

Does child exhibit any behavior that would be considered dangerous to himself or others?

Yes

No

Please Explain

Responsible Party

Primary

Last Name

First Name

Age

Date Of Birth

Sex

Male

Female

Relationship to client

Social Security Number

Main Phone/Mobile

Secondary Phone/Mobile

Email

Secondary

Last Name

First Name

Age

Date Of Birth

Sex

Male

Female

Relationship to client

Social Security Number

Main Phone/Mobile

Secondary Phone/Mobile

Email

Emergency contact

Last Name

First Name

Relationship to client

Main Phone/Mobile

Expectations for ABA therapy

Patient Release & Acknowledgement

I verify that the information I have provided is correct to the best of my knowledge

I authorize the release of medical information necessary to receive benefit information, treatment authorization and in order for ABC to process claims through insurance companies and their agencies.

I have attached a diagnosis report AND the referral form from my childs medical doctor

I have completed all required portions of this document and understand that incomplete or illegible

Full name of insured or authorized person

Date / Time

I consent to have this website store my submitted information so they can respond to my inquiry

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