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. We do not provide home-based ABA therapy.

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, do NOT proceed, as 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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