Request Form - ABA Squad

Child First Name*
Child Middle Name (if on insurance card)*
Child Last Name*
Child Date of Birth*
Child Age*
Child Gender*
Parent/Guardian*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian Email*
Parent/Guardian Home Phone*
Parent/Guardian Mobile Phone*
Upload a copy of the child's diagnosis report.*
Select the type of coverage your child has.*
- Select All
- Private insurance
- Medicaid/state program
- Private Pay
Upload a copy of the front of the insurance/medicaid card.
Drop files here or
Upload a copy of the back of the insurance/medicaid card.
Drop files here or
Consent To Use PHI*
By clicking this box you are giving ABA Squad permission to use or disclose your protected health information (PHI) for treatment, payment and health care operations purposes.
Request For Assistance
If you are unable to upload the requested images, please check this box and our intake team will get in touch with you.

Intake Team will contact you in 3 business after the completion of this online form. We looking forward to speaking with you!