ABA Pre Screen

ABA New Patient Request Pre-Screen

Please fill out this form entirely. Someone from our team will review it and reach out as soon as possible to confirm that your child has been added to the waitlist.
Understanding ABA

Applied Behavior Analysis (ABA) therapy is a widely recognized treatment for individuals with autism spectrum disorder (ASD) and other developmental disorders that focuses on improving specific behaviors and skills through structured and individualized interventions. In the state of South Carolina, insurance coverage for ABA therapy requires both an official autism diagnosis and an ADOS (Autism Diagnostic Observation Schedule) assessment. Without these, services will be considered private pay and will not be covered by insurance.
Does your child have a confirmed autism diagnosis with a completed ADOS assessment?*

YesNo
PLEASE NOTE:

You will be required to provide us with a copy of the diagnositic report for your childs autism diagnosis. It may be uploaded to this prescreen at the end or provided to us at a later time. We will be unable to start an evaluation without this report. Thank you
In South Carolina, ABA requires a diagnosis of Autism for insurance to provide coverage. At this time you have indicated your child does NOT have this diagnosis and our clinic would be unable to provide ABA. If you would like more information on our psychological testing and autism screening, please visit our testing website by clicking this link Firefly Therapy Clinic Psychological Testing.

If you have more questions about Firefly Therapy Clinic and ABA services, please contact our office directly at 864-775-6685.

Thank You
ABA Treatment Expectations – Please Read Before Proceeding

As part of the ABA intake process, a Board Certified Behavior Analyst (BCBA) will complete an initial evaluation and recommend a treatment plan that includes the number of therapy hours per week. Most children are recommended between 25 to 30 hours per week, with some requiring up to 40 hours depending on individual needs. If you choose to move forward with ABA services, we ask that you commit to attending for the full number of hours recommended by the BCBA. At this time, we are unable to accommodate reduced hours once the evaluation is complete, as consistency and intensity are key components of effective treatment. If your family is unable to commit to a schedule of up to 8 hours per day, 5 days per week, please let us know in advance so we can determine if a part-time option may be available. Thank you for your understanding and for working with us to support your child’s progress.
Todays Date

MonthDayYear
Date
Child's Name *

First NameLast Name
Childs Date of Birth*

MonthDayYear
Please note: We only accept new patients between the ages of 1-11.
Child's Gender *
Parent/Guardians Name *

First NameLast Name
Email *
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select ALL insurances your child is currently covered by. (At this time, we do not accept Healthy Blue, Molina, Absolute Total Care, or Tricare insurances)*

Healthy Connections/TEFRAFirst Choice by Select HealthBlue Cross Blue ShieldAETNACignaUnited HealthcareHumanaMagellanMolinaHealthy BlueOther
If you answered 'Yes' please provide the name and credential of the diagnosing doctor. If you answered 'No' please provide the date in which the evaluation will be conducted.*
Does your child have an ABA referral from their primary care physician?*

YesNo
Which days and times is the child available for therapy? (NOTE: depending on the level of severity children are often prescribed 10-20 hours per week for low severity, 20-30 hours per week for moderate severity, 30-40 hours per week of high severity)(choose the one that best describes your child most of the time)*

5 days per week any time of day3-4 days per week any time of dayLess than 3 days per weekHalf-days or afterschool only
Staffing for in-home treatement is limited. We try to occomodate in home when its part of the childs Plan of Care, otherwise treatment will most commonly be provided in clinic. Will you be able to bring the child to our clinic unless in home treatment is reccommened*

Yes, most days and times work for me.It will depend on the schedule, but I am somewhat flexibleI can only drop off and pick up at specific times each dayNo, coming to the clinic is not an option for us
Pre-Screen Behavioral Questionnaire

Please choose an answer(s) for each question that best describes your child.
How does your child make requests for items and activities? (choose the one that best describes your child most of the time)*

Pulling people, pointing, grabbingSpeaking in words or phrases ONLY after someone else says them first (e.g., echoed, repeated, scripted)Saying the names of desired items ( 5-25 words)Spontaneous words and phrases ( 0-25 words)Spontaneous words and phrases ( 50-100 words)Conversational speech (more than 200 words)
What challenging behaviors does your child exhibit on a regular basis? (check all that apply)*

Aggression (like hitting, biting, scratching)running from peopleRefusalTantrumSelf-injuryScreamingOther
How does your child socialize with peers? (choose the one that best describes your child most of the time)*

Plays alone whenever possiblePlays near children but does not interact independently (e.g., parallel play)Independently engages in turn-taking activitiesReadily shares and interactively participates in creative play activities, such as role-play, board games, and tag
Please list all current diagnoses your child has.
Please list all needed medical treatment your child currently uses DAILY. (e.g., nebulizer, inhaler, prescriptions, epipen)?
Please upload any documents to expedite the onboarding process. (Ex: ADOS, Referral, Insurance Cards, etc)

Browse Files
This is not required at this time but will be once onboarding begins. Cancelof
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ABA New Patient Request Pre-Screen

Understanding ABA

ABA Treatment Expectations – Please Read Before Proceeding

Pre-Screen Behavioral Questionnaire