Enrollment Form

Enrollment Form
Parent/Guardian Information
Parent/Guardian Information*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Do we have permission to leave a voicemail or send an email if we cannot get a hold of you?*

YesNo

CLINICAL/DIAGNOSIS
Purpose of Inquiry/Primary Concerns*
Were you referred to ABA by your Primary Care Physician?*

YesNo
Name of Primary Care Physician

First NameLast Name
Has your child received a psychological evaluation with an Autism diagnosis?*

YesNo
Please Attach Psychological Evaluation Report

Cancelof
What services are you looking for?

Receiving an assessment (new to ABA)Continuation of services (transferring from other provider)
Name of previous ABA provider*
Please attach most recent progress report or exit report from previous ABA provider

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CONFIRMATION/SUBMIT
How Did You Hear About Us?

EBTS StaffEBTS ClientFacebook AdFriend ReferralInsuranceRegional CenterOther
I, First Name* Last Name*, authorize the release of insurance and benefits information to Elevated Behavioral Therapy Services. I understand that a quote of benefits and/or authorization does not guarantee payment from my insurance company. Payment of benefits is subject to all terms, conditions, limitations, and exclusions of the member’s contract at time of service. I understand that I am responsible for alerting my ABA provider of any changes in my insurance and/or payment status for services.
Please verify that you are human*
Signature*

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Parent/Guardian Information