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.
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
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Month
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Day
Year
Date
Child's Name
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First Name
Last Name
Childs Date of Birth
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/
Month
/
Day
Year
Please note: We only accept new patients between the ages of 1-11.
Child's Gender
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Please Select
Male
Female
Parent/Guardians Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Area Code
Phone Number
Address
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Street Address
Street Address Line 2
City
State / 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)
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Healthy Connections/TEFRA
First Choice by Select Health
Blue Cross Blue Shield
AETNA
Cigna
United Healthcare
Humana
Magellan
Molina
Healthy Blue
Other
Does your child have a confirmed autism diagnosis with a completed ADOS assessment?
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Yes
No
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.
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Does your child have an ABA referral from their primary care physician?
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Yes
No
Which days and times is the child available for therapy? (NOTE: depending on the level of severity children are often prescribed 10-15 hours per week for low severity, 20-25 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)
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5 days per week any time of day
3-4 days per week any time of day
Less than 3 days per week
Half-days or afterschool only
Please select which location you are requesting therapy in.
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In clinic
In home
Hybrid (mix between clinic and home)
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)
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Pulling people, pointing, grabbing
Speaking 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)
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Aggression (like hitting, biting, scratching)
running from people
Refusal
Tantrum
Self-injury
Screaming
Other
How does your child socialize with peers? (choose the one that best describes your child most of the time)
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Plays alone whenever possible
Plays near children but does not interact independently (e.g., parallel play)
Independently engages in turn-taking activities
Readily 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.
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