Moving Mountains Bx Service Request
Please fill out this questionnaire and you will be automatically populated onto our waitlist. Our admin team will contact you when a spot has become available in our center. Currently waitlist times cannot be quantified, but please contact our office with any questions or updates. We'd be happy to assist! Please note: 1. If we are not in-network with your current insurance, we cannot add you to our waitlist. 2. We do not provide services in home. 3. We organize our submissions by availability, your waitlist position may be different based on your availability for sessions. Thank you for choosing us to be your ABA provider!
Parents Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Client's Name
Client's Date of Birth
/
Month
/
Day
Year
Date
Tell us a little bit about your son/daughter, family member, or yourself!
If we do not have an opening that fits your needs, would you like to be placed on our waitlist for 1:1 ABA Services?
Yes, please place me on the waitlist
No, I wouldn't like to be placed on the waitlist.
I am currently receiving ABA services elsewhere, but would like be placed on your waitlist.
Primary Insurance
Secondary Insurance
Waitlist Information
As mentioned above, depending on what availability you select below you will be categorized for each time block. Your waitlist position may be different under each block. For example, you might be #10 for Morning Availability, but #30 for Afternoon/Afterschool. Thank you for your cooperation!
Availability for In Clinic-Center ABA Services (Click all that apply)
Morning
Before school (before 9am)
Early Afternoon
Afternoon/After school
Flexible Schedule
Does your child receive Speech, OT, and/or PT If so what is their current schedule?
Is your child currently attending school or daycare?
Yes school
No School (Not of age yet)
Homeschool
Daycare
School and Daycare
Currently our afternoon availability has a longer waitlist than morning availability. Would your schedule/availability between 8am-12pm, or 9am-1pm be an option if it means a considerably less wait time? We do provide excusal notes to send to school upon request.
Yes
No
Unsure at this time
Yes, for certain days a week and with school excusal note (M, W, F) or (T, TH)
What is your language preference for emails, phone calls, and paperwork? (English, Spanish, ETC.)
English
Spanish
Spanish, but I am able to still communicate in english.
Other
Comments
Submit
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