Inquiry Form
Child's First & Last Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Child's Primary Language
*
Parent/Guardian
*
First Name
Last Name
Parent/Guardian
First Name
Last Name
Parent's Primary Language
*
Primary Care Physician Name
example@example.com
Primary Care Physician Phone number
example@example.com
Child's home address
example@example.com
Parent's Email
*
example@example.com
Mobile Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Insurance
*
e.g. Anthem, Humana, UHC etc.
Primary Insurance ID number
*
e.g. Anthem, Humana, UHC etc.
Primary Insurance ID#
*
Interest Services
*
Center Based ABA Therapy
Behavior Consulting
Parent Training
Occupational Therapy
Speech Therapy
Other
Location
*
Ottawa
Findlay East
Findlay West
Van Wert
Lima
Defiance
Upper Sandusky
Bryan
Name of Individual Submitting Inquiry
First Name
Last Name
Uploading documentation
In order to know if your child's insurance coverage allows ABA therapy, please upload a copy of your insurance card, front and back. Our team will check those benefits and let you know benefit information and if there is any cost associated with those services. To move forward with enrollment process, a complete copy of the diagnostic report is needed where your child was given the diagnosis of ASD. Please upload that if you have it. Please email enrollment@monarkaba.org if you have any questions regarding this form. Thank you.
Insurance Card
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Diagnostic report
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Submit
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