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ABA Therapy
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Contact
Home
About Us
Services
ABA Therapy
Early Intervention
Social Skills
Parent and Teacher Training
Tutoring
School Readiness
Insurances
Request Services
Work With Us
Contact
Services Request Form
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
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Alaska
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Texas
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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.
Our Intake Team will contact you after the completion of this online form. We looking forward to speaking with you!