ABA Service Request

Please complete this form to submit a request for ABA Therapy. Please note that we do NOT accept Medicaid. Click on the “Behavioral Services” tab to see a list of insurance accepted. Services are center-based and school-based (for charter or private schools) only.

Name
First Last
Full Name of Child / Client to receive services*
Child Date of Birth (DOB) / Client to receive services*
MM
DD
YYYY
Phone*
Address of Subscriber
Street Address Address Line 2 City State ZIP Code
Insurance Company (We DO NOT accept Medicaid, Aetna Administrators, Beacon, Healthscope, or Tricare)*
Hold 'CTRL' to select more than one option (e.g., Aetna with ATAP Insurance Assistance Plan. If you do not see your insurance listed, we are not in-network
Plan Name (e.g, ATAP Insurance Assistance, Aetna Choice POS, etc.)*
What part of town do you reside? (e.g., Summerlin, The Lakes, etc).*
Used for scheduling purposes
Email*

Only used to return correspondence. Your information will not be used for anything else.
Areas of Concern / Focus of Treatment*
Hours child/client is available for ABA Therapy
- 8:00am-10:00am
- 10:00am-12:00pm
- 12:00pm-2:00pm
- 2:00pm-4:00pm
- 4:00pm-6:00pm
- 6:00pm-8:00pm
Check all that apply
Insurance Card (Front/Back)
Drop files here or
Please upload a copy of your insurance card. Include both the front and the back.
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