Inquiry Form | Autismness ABA

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Autismness ABA

An Applied Behavioral Analysis Clinic

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Client Intake Form * Indicates required fields

Child's First Name*

Child's Last Name*

Birthday*

Month

Day

Year

Does your child have an Autism Diagnosis within the last 3 years?*

Yes

No

Does your child have an Autism Diagnosis?*

Yes

No

Has your child received ABA services within the last 6 Months?*

Yes

No

What is your Child's primary insurance provider*

What is your child's secondary insurance provider

Parent First Name*

Parent Last name*

Insurance Subscribers Full Name*

Insurance Subscribers DOB MM/DD/YY*

Your Phone #*

Your Email Address?*

Zip Code*

Are you willing and able to commit to attend and consistently arrive on time to your child's scheduled therapy appointments? We require a minimum 95% attendance rate.*

Are you willing and able to commit to utilizing 90% or more of the medically appropriate level of care, as determined by your child's Behavior Analyst?*

Service Location Request*

Clinic-Based

In-Home

MDE School

Other School

How did you hear about us?*

Insurance Card(S) ( Front & Back)*

Step 1: Client Intake Form

12060 Etris Rd Ste 200 Roswell GA 30075 | Phone # 770-557-0945 | Fax # 470-545-0975

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