Let's Get Started - ABA Services
Please note that our in-home services are available in Killeen only.
Patient Information
DateTime
Patient Name
First Name
Last Name
Parent/Guardian Name
First Name
Last Name
Phone
Please enter a valid phone number.
Date of Birth
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are there skills that you would like to improve?
Communication
Social Skills and relationships
Community Safety
Self Help
Other
Are there interferring behaviors that you would like to decrease?
Aggression
Self Injury
Property Destruction or Throwing
Elopement or leaving a space
Yelling / Screaming / Shrieking
Other
Insurance Information
**Tricare Families - Please do not upload military IDs**
What payment/insurance will you be using?
Please Select
BCBS - PPO
Tricare - Select
Tricare - Prime
Cigna
At this time, we are not accepting Medicaid Clients
Insurance Subscriber Name
First Name
Last Name
Subscriber Date of Birth
-
Month
-
Day
Year
Date
Group #
Member ID
Front of Insurance Card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back of Insurance Card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Diagnosis Information
Does the learner have a current Autism Diagnosis?
Please Select
Yes
No
We are awaiting evaluation
Depending on payor - this documentation may be required upon intake
Current Autism Diagnostic Report
Browse Files
Drag and drop files here
Choose a file
Typically Required by Insurance Payors for Pre-authorization
Cancel
of
Does the learner have a current referral for ABA treatment?
Please Select
Yes
No
Awaiting referral
Referral is no required by insurance
Depending on payor - this documentation may be required upon intake
Current Referral for ABA Services
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Previous Experience with ABA
Have you received ABA before?
Please Select
Yes
Yes, it as more than 1 year ago
No
If Yes, what was your experience?
Please Select
Positive
Mostly Positive
Neutral
Mostly Negative
Negative
What are you looking for in new ABA provider?
Type of services requested:
Please Select
In-Home Services (All Ages 2-18 yrs)
Center-based Services (2-5 yrs)
Parent-training Only
Something Else
Service Availability
CENTER BASED- Preschool & Early Learner Services 2 years - 5 yrs
Mon
Tues
Wed
Thurs
Fri
8:30am -11:30am
11:30am - 3:30pm
8:30-3:30pm
IN-HOME ABA Services - All Ages - Killeen Only
Mon
Tues
Wed
Thurs
Fri
8:30-11:30am
12:30pm-3:30pm
3:30pm-5:30pm
4:00pm-6:00pm
What date would you be available to start?
Is there any other information that you would like us to know?
Submit
Should be Empty: