BX Fluency_Service Request 2025

New Member Form
MEMBER INFORMATION
Member Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has the member received a medical diagnosis of Autism Spectrum Disorder?*

YesNo
Diagnosis was provided by (Physician Name and Office Name)
Please list any additional diagnoses:
Requested Service:*

Morning ABA, 8:00 - 12:00 at Pilot OfficeMorning ABA, 9:00 - 3:00 at Pilot OfficeAfternoon ABA, 1:00 - 5:00 at Pilot OfficeMorning ABA, 9:00 - 2:00 at Stephanie OfficeAfternoon ABA, 3:00 - 6:00 at Stephanie OfficeSchool / Daycare
School / Daycare Information
Please provide name and address
*All ABA programs are Monday through Friday

Pilot Office: 731 Pilot Road Suite L Las Vegas, NV 89119

Stephanie Office: 375 N Stephanie Street Suite 1514 Henderson, NV 89015
PARENT / GUARDIAN INFORMATION
Parent / Guardian Name:*

First NameLast Name
Relationship to Member*
E-mail*
example@example.com
Phone Number:*
INSURANCE INFORMATION
Primary Insurance*
Secondary Insurance
Additional Notes:
How did you hear about us?*
Upload Insurance Card*

Cancelof
Upload Diagnosis Document / Referral

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Upload IEP (if applicable)

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Should be Empty:

New Member Form