Services & Availability Inquiry Form

Services & Availability Inquiry Form

Thank you for your interest StarBright ABA to help you meet the needs of your child! With the information below, we can see if our services and availability will be a good fit based on your child's needs, insurance, and schedule. We will contact you within a couple of business days to discuss. We look forward to connecting with you!
Contact Information

Telephone: 845-863-5208 • www.StarBrightaba.com • 118 River Road, Suite 14 Harriman, NY 10926
Client Information
First NameLast Name
Gender
Date of Birth*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does student have a prescription for ABA services?*

YesNo
Primary Language Spoken by Client:
Primary Caregiver Information
First NameLast Name
Phone Number
Please enter a valid phone number.
Email*
example@example.com
Relationship to Client
Primary Language Spoken in the Home:
How did you hear about us? Referred by: .
How did you hear about us?
Reason for Request
Behavioral Concerns (select all that apply)

Aggression to self (SIB)Aggression to othersInflexible routinesSelf-stimulatory behaviorsProperty destructionOther behaviors that interfere with your child's daily routines
Support with Activities of Daily Living (select all that apply)

BathingDressingToiletingFeedingMorning RoutinesBedtime Routines
How does your child:
Express his/her needs (i.e., vocal, gesture, cry)?
Respond to requests?
Referral / Insurance Information
Current Service Provider
Previous Service Provider
Name of Diagnosing Physician
Physician Phone Number
Please enter a valid phone number.
Insurance Primary Policyholder

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to Client

MotherFatherSelfOther
Insurance Provider
If 'Other', please specify
Insurance ID
Insurance Card Front
Insurance Card Back
Hours Available for ABA Services (select all that apply)

MorningAfternoonEvening
Days Requesting Services (select all that apply)

MondayTuesdayWednesdayThursdayFriday

Availability

	Monday	Tuesday	Wednesday	Thursday	Friday
AM
Midday
Afterschool

IMPORTANT: Before we can verify your coverage with your insurance company, we need a copy of the front and back of your insurance card. Please scan or snap a picture of both sides and submit them in this form or to info@starbrightaba.com. If you require assistance, please call us at 845-863-5208 or email us.

A quote of benefits and/or authorization does not guarantee payment. Payment of benefits is subject to all terms, conditions, limitations, and exclusions of the member’s contract at the time of service. *** You will always be solely responsible for letting your provider know about any changes in insurance and or payment status for services. Any services not fully covered by insurance will be the responsibility of the patient/family.

Privacy Disclaimer: StarbrightAba will never sell your information to any third party person we are committed to protecting your personal information and your right to privacy.
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Services & Availability Inquiry Form

Contact Information

Client Information

Primary Caregiver Information

Reason for Request

Referral / Insurance Information