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PLEASE NOTE THAT WE WILL BE CLOSED ON THE FOLLOWING DAYS IN APRIL: TUESDAY & WEDNESDAY 4/23 AND 4/24; MONDAY AND TUESDAY 4/29 AND 4/30
We will reach out to all who contact us the first business day we are back after each of these closures.
On Target ABA Pre-intake Form
Ready to get your child started started? Please fill out this form!
Child's Name (preferably as spelled on insurance card)
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Location
*
Cleveland
Columbus
Akron
Service Setting
In-center
In-home
In-home & In-center
In School
In Child's Daycare
Not Sure
Other
Contact Name
First Name
Last Name
Relationship of Contact to Child
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance
Please Select
Aetna
Anthem
Buckeye
CareSource
Cigna
Cleveland Clinic Plan (Aetna)
Medical Mutual
Molina
Other
Paramount
UMR
United Communnity Plan (Medicaid)
United (Commercial)
Name of Insurance Plan
Does the child already have an autism diagnosis?
*
Yes
No
Not Sure
If yes, what was the name of the facility and/or doctor who diagnosed them?
Does the child attend school? If so, what days and hours?
*
What days an times are you available for therapy?
Any other information you would like to share with us about your child
How did you hear about On Target ABA?
*
Please upload your insurance card here, or email it to intake@OnTargetABA.com.
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If you have the child's autism evaluation report, please upload it below or email it to intake@ontargetaba.com. If you don't have a digital copy available, that's ok; we can help you obtain one from the diagnosing facility later.
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PLEASE NOTE THAT WE WILL BE CLOSED ON THE FOLLOWING DAYS IN APRIL: TUESDAY & WEDNESDAY 4/23 AND 4/24; MONDAY AND TUESDAY 4/29 AND 4/30
We will reach out to all who contact us the first business day we are back after each of these closures.
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