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.

Our ABA Services
At Juniper Health & Wellness, we provide family-centered ABA therapy designed to help individuals of all ages thrive. Whether we’re supporting a young child, teen, or adult, our collaborative approach actively involves caregivers and families when appropriate—empowering each client with practical tools, compassionate support, and research-backed strategies to make meaningful progress in everyday life.

We offer flexible scheduling Monday through Friday to fit your lifestyle. Services are available in-home or via telehealth, and each care plan is tailored to the individual’s unique goals, strengths, and support needs.

We accept cases with a minimum of 10 hours per week, based on research-supported guidelines from the Council of Autism Service Providers, which outline the intensity required for ABA to be most effective. We do make exceptions based on availability.

Before You Apply
Here’s what you need to know before getting started:

Assessment Timeline:
There is typically a 1-month wait between authorization and the start of services.

To complete your application, please have the following ready:

Copies of your insurance card (front and back)
Insurance policy information
Diagnostic report or evaluation summary (e.g., autism diagnosis documentation)

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 Phone Number (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.

Application for ABA Services

Patient & Parent Information

Juniper Health - Insurance Information & Verification of Benefits

Patient Autism Diagnosis Information

ABA Service History Information