Application for ABA Services

Application for ABA Services
Welcome to Juniper Health & Wellness!
Thank you for your interest in our services—we're honored to partner with you and your family on this journey.

This application collects all the information we need to get started. If you're not quite ready to apply but would like a consultation, please reach out to us at (254) 294-4488 or email hello@juniperhw.com.

Before You Start...
Here’s what you need to know before getting started:
1. Copies of your insurance card (front and back)
2. Diagnosis / Evaluation Report
3. ABA referral
If you don't have the diagnosis evaluation or the ABA referral, they can be faxed to: 512-367-5738 or sent to us through LeadingReach.

Questions?
We’re here to help.
Call: (254) 294-4488
Email: hello@juniperhw.com

We look forward to supporting you and your loved ones soon!

Patient & Parent Information
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Parent/Guardian Name 1*

First NameLast Name
Phone Number (Parent/ Guardian 1) *
Please enter a valid phone number.
Email (Parent/ Guardian 1) *
example@example.com
Parent/Guardian Name 2

First NameLast Name
Phone Number (Parent/ Guardian 2)
Please enter a valid phone number.
Email Phone Number (Parent/ Guardian 2)
example@example.com
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Language or Cultural Issues that should be considered?

Juniper Health - Insurance Information & Verification of Benefits
Insurance Company Name*
Please note: If the insurance is not listed, we are not in-network with them.
Member ID or Sponsor ID
Group Number
Tricare Patients - Please Skip This Step
Insurance Subscriber Name

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Date
Front of Insurance Card

Tricare Patients - Please Skip This Step
Cancelof
Back of Insurance Card

Tricare Patients - Please Skip This Step
Cancelof
Does the patient have secondary insurance?
Please be aware that if this information is not provided, the parent or guardian may be directly billed for the services.
Is this a self-funded plan?
Services can only be provided for self-funded plans up to the 'paid through' date.