Start your path to progress.

Please complete this form with as much detail as possible to help us process your information swiftly. Our current wait time is approximately 6 months, and having your information ready will ensure we're prepared to move forward when a spot opens. After submitting, look for a follow-up email from us to proceed with the next steps. Thank you and we look forward to journeying the way together.

PATIENT (CHILD) INFORMATION

Patient's First Name

Patient's Last Name

Patient's Date of Birth

Month

Day

Year

Patient's Gender

Main Behavioral Concerns

Questions?

Has the patient received the following?

An Autism (F84.0) Comprehensive Diagnostic Report?

Yes

No

If yes, please upload.

Comprehensive Diagnostic Evaluation must include:

a written diagnosis of Autism Spectrum Disorder with code F84.0
the credentials and signature of the diagnosing provider (such as a pediatric neurologist, developmental pediatrician, licensed psychologist, or psychiatrist)
A narrative summary of how the diagnosis was reached
results from multiple standardized tools or assessments (e.g., ADOS-2, Vineland, Mullen Scales, developmental history, etc.)
clinical observations and impressions
final diagnosis

A Referral for ABA therapy?

Yes

No

If yes, please upload.

Referral for ABA therapy, must include:

a formal diagnosis of Autism Spectrum Disorder with code F84.0 made by a qualified provider (neurologist, developmental pediatrician, psychologist, or psychiatrist)
the credentials and signature of the diagnosing provider with date (such as a pediatric neurologist, developmental
a clear statement referring the child for ABA therapy
must be dated within the last 6 months

ABA therapy somewhere else?

No

Yes, name & location:

An IEP (individualized education plan) or 504 Plan for school?

Yes

No

Do you have a preferred setting for the therapy sessions?

Do you have a preferred setting for therapy sessions?

Clinic

Home

School

Do you have preferred times for the therapy sessions?

Session Times (select all that apply)

9am - 12pm

12pm - 3pm

3pm - 6pm

School Name:

School Name

School Address

PARENT / CAREGIVER INFORMATION

Parent / Caregiver First Name

Parent / Caregiver Last Name

Phone

Email

Relationship to Patient

Home Address

City

State

Zip /Postal Code

FINANCIAL RESPONSIBILITY

Please note: We are currently contracted with the insurance companies listed below.

Primary Insurance

Primary Insured Person Full Name (1st insurance)

Date of Birth (1st insurance)

Gender

Relationship to Patient (1st insurance)

Upload front of insurance card (1st insurance)

Upload back of insurance card (1st insurance)

By submitting my insurance card, I authorize ABA Way, LLC to verify my coverage for ABA services. I understand this information will be used solely for verifying insurance and estimating any out-of-pocket costs. Submission is voluntary, and I may revoke this authorization at any time by notifying ABA Way, LLC in writing.

Secondary Insurance

Secondary Insurance Company Name

Main Insured Person Full Name (2nd insurance)

Date of Birth (2nd insurance)

Gender

Relationship to Patient (2nd insurance)

Upload front of insurance card (2nd insurance)

Upload back of insurance card (2nd insurance)

By submitting my insurance card, I authorize ABA Way, LLC to verify my coverage for ABA services. I understand this information will be used solely for verifying insurance and estimating any out-of-pocket costs. Submission is voluntary, and I may revoke this authorization at any time by notifying ABA Way, LLC in writing.

Thank you for reaching out and for your commitment to your child’s journey. At this time, we have a waiting list of approximately six months. We will contact you as soon as we are able to begin the onboarding process. We truly appreciate your patience and look forward to welcoming your child when a spot becomes available.