Intake Application for ABA Services
Parent/Legal Guardian(s) Information
Parent or Legal Guardian Name:
*
First Name
Last Name
Best Contact Phone Number:
*
-
Area Code
Phone Number
Email (status updates will be sent through email):
*
example@example.com
Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Information
Child's Name:
*
First Name
Last Name
Child's Age:
*
Child's Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's School (daycare/school name) or specify if home school:
*
Child's Grade:
*
Please list the child's diagnosis and if none enter "N/A":
*
Does the child have a referral for ABA services? *Most insurances require a referral from an MD, but not all. This will depend on your individual insurance plan*
*
Yes
No
Insurance Information
Primary Insurance Company:
*
Please Select
Aetna
Blue Cross Blue Shield
Cigna
Curative
FES-UA Scholarship
CMS Molina
Primary Insurance ID Number:
*
Name of Secondary Insurance Company *If you have private insurance and Medicaid for your child, Medicaid is secondary*:
Secondary Insurance ID Number:
Please answer the following questions to the best of your knowledge.
Why are you seeking ABA services?
*
Where are you looking to receive services? Check all that apply.
*
Clinic located at 1260 West Bay Dr, Suite B, Largo, FL 33770
Home
School or Daycare
Other
What times will you be available for services? This will help us determine if we have a provider that matches your availability.
*
Daytime Hours Only (before 3pm)
After School Hours Only (between 3pm-6pm)
Flexible (daytime and/or after school)
Preschool / School Prep Program in clinic 8:30am-2:30pm
Other
What times are you available for services?
*
Daytime Hours Only (Between 8:30AM-3PM)
After School Hours Only (Between 3PM-6PM)
Flexible (Daytime and/or after school)
Other
Name of person completing this application:
*
First Name
Last Name
Signature of the person completing this application:
*
Submit
Should be Empty: