Client Enrollment Form

1
Hi! Let's get started. First, what's your name?* This field is required.Please type the name of the client's parent/legal guardian
First Name
Last Name
2
A good email address?* This field is required.
example@example.com
3
What's a good phone number to reach you at?* This field is required.
Please enter a valid phone number.
4
And, what is the client's street address?* This field is required.
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Who should we contact in case of emergency other than yourself?* This field is required.
First Name
Last Name
6
What is a good number to reach them at?* This field is required.
Please enter a valid phone number.
7
And, what is the client's name?* This field is required.
First Name
Last Name
8
Client's date of birth?* This field is required.
Date
Month
Day
Year
9
Client's gender?* This field is required.
Male
Female
Other
10
What is the name of the diagnosing provider? * This field is required.Aside from in rare and unusual circumstances, a diagnosis of autism spectrum disorder (ASD) is required by insurance providers for ABA therapy coverage. Please specify if you have confirmed ABA coverage for a different diagnosis in the notes section at the bottom of this form. Please contact our office if you do not meet the criteria for insurance coverage and would like to inquire about our private pay option. Thank you!
First Name
Last Name
11
Please upload a copy of the client's diagnosis * This field is required.Aside from in rare and unusual circumstances, a diagnosis of autism spectrum disorder (ASD) is required by insurance providers for ABA therapy coverage. Please specify if you have confirmed ABA coverage for a different diagnosis in the notes section at the bottom of this form. Please contact our office if you do not meet the criteria for insurance coverage and would like to inquire about our private pay option. Thank you!
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12
What is the name of the client's primary care physician?* This field is required.Please type the name of the referring physician here
First Name
Last Name
13
Who is your primary insurance provider?We accept BCBS plans with ABA specific coverage, AllKids, and Tricare. Please contact your insurance provider to confirm coverage prior to enrollment. While we do not accept Medicaid at this time, we encourage you to proceed with form completion as we hope to apply for credentialing with Medicaid in the future.
BCBS
AllKids
Tricare
Medicaid
Other
14
If insured, who is your primary insurance provider?* This field is required.
15
What is the insurance contract holder’s name?* This field is required.
First Name
Last Name
16
What is the insurance contract holder's date of birth? * This field is required.
Date
Month
Day
Year
17
Please type the policy number or insurance id number below* This field is required.
18
What is the policy group id number? * This field is required.
19
Please upload a copy of the front of the client's primary insurance card here* This field is required.FRONT
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20
Please upload a copy of the back of the client's primary insurance card here* This field is required.BACK
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21
Do you have a secondary insurance provider? If so, who?
22
Please upload a copy of the front of the client's secondary insurance card here, if applicable.FRONT
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Max. file size: 10.6MB
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23
Please upload a copy of the back of the client's secondary insurance card here, if applicable.BACK
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24
Who lives in the home?* This field is required.Please list names, ages, and relationship to the client of everyone who lives in the home.
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25
Are there any religious or cultural preferences we should be aware of?Imagine ABA prides ourselves on individualized inclusivity. Please let us know how to best accommodate your needs.
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26
Does the client have any allergies or medical conditions requiring specialized care?* This field is required.
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27
Does the client attend school? If so, what school does the client attend?* This field is required.Please list the name of the school, daycare, or preschool program your child attends.
28
Does the client receive special education services? If so, please describe the services received below.* This field is required.
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29
Please upload a copy of the most recent IEP here if applicable
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30
Has the client received ABA services in the past? If so, please list the names of the company and dates of service below. * This field is required.
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31
Please upload the client’s most recent treatment plan, if applicable
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32
What concerns would you like to address via Applied Behavior Analysis?* This field is required.Please list your concerns using as much detail as possible.
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33
Please choose your availability for therapy from the options below:* This field is required.Helpful hint- Clients are typically with us 6-30 hours per week depending on client and/or clinic availability and diagnostic severity.
Full-Time (Mon-Fri 8:00-2:00)
Wednesday 8:00-2:00
Monday 8:00-2:00
Wednesday 3:00-5:00
Monday 3:00-5:00
Thursday 8:00-2:00
Tuesday 8:00-2:00
Thursday 3:00-5:00
Tuesday 3:00-5:00
Friday 8:00-2:00
34
What does your availability look like?What days and times are you available for therapy?
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35
Additional Notes:
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36
Date Submitted:* This field is required.
Date
Year
Month
Day
37
Signature* This field is required.By signing and submitting, I acknowledge that I am entering a HIPAA protected agreement as a client of Imagine Applied Behavior Analysis. The the information I have provided is truthful and accurate. I understand that this information will be securely and safely stored in accordance with the laws and principles of a HIPAA protected relationship.
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