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 Office
*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

BX HQ services may be funded through health insurance if the member's plan includes ABA and authorizes participation in our program. If insurance coverage is not approved or not available, members have the option to enroll through our monthly membership program, which includes access to scheduled group sessions, open club hours, and priority registration for workshops and events.
Primary Insurance*
Secondary Insurance
Additional Notes:
How did you hear about us?*
Upload Insurance Card*

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Upload Diagnosis Document / Referral

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Upload IEP (if applicable)

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Should be Empty:

New Member Form

MEMBER INFORMATION

PARENT / GUARDIAN INFORMATION

INSURANCE INFORMATION