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• Intake Portal

ABA Enrollment

Please complete all required sections below to initiate Applied Behavior Analysis support services for your child. Ensure all personal details match official medical records.

Client Information

Enter the legal identity and primary residence details for the child receiving behavior support services.

Annotation Note

The client date of birth and full legal name must exactly match the records on your insurance card to prevent verification delays.

Guardian Information

Provide contact details for the parent or legal representative responsible for treatment authorizations and scheduling.

Communication Notice

This email and phone number will receive evaluation reminders, IEP consultation notes, and security access details.

Insurance Information

Please enter primary health benefit plan details to facilitate direct insurance authorization for ABA therapy.

Attestation & Privacy

Your completed intake information is transmitted securely following HIPAA compliance guidelines to protect client healthcare records.

I acknowledge and attest that the information provided above is all accurate and correct