Form
Behavior Speaks ABA - New Client Intake Form (HIPAA Secure)
Please complete this form to request ABA services. Submitting this form does not guarantee immediate placement. We will contact you within 1-2 business days.
Parent/Guardian Full Name
*
Parent/Guardian First Name
Parent/Guardian Last Name
Parent/Guardian Email
*
example@example.com
Parent/Guardian Phone
*
Please enter a valid phone number.
Best way to contact you
*
Please Select
Call
Text
Email
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Information
Client Full Name
*
First Name
Last Name
Client Gender (optional)
Please Select
Female
Male
Non-binary
Prefer not to say
Primary Language Spoken at Home
*
Does your child have an Autism diagnosis?
*
Please Select
Yes
No
Unsure
Diagnoses (check all that apply)
*
Autism Spectrum Disorder (ASD)
ADHD
Anxiety
Developmental Delay
Speech/Language Delay
Intellectual Disability
Other
Insurance Information
Primary Insurance Company
*
Please Select
Aetna
Capital Blue Cross
Geisinger
Highmark
UPMC
PerformCare
Medicaid / Medical Assistance
Other (please specify)
If Other, please type insurance name:
Subscriber Name
Subscriber Date of Birth
-
Month
-
Day
Year
Date
Member ID
*
Group Number
Pennsylvania Medical Assistance (Medicaid/MA)
*
Please Select
Yes
No
Not sure
Upload Documents
Uploading documents helps us verify benefits faster and reduces delays.
Upload Insurance Card (Front)
Browse Files
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Choose a file
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of
Upload Documents (Back)
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Upload Diagnostic Evaluation / Diagnosis Letter
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Upload IEP / School Documents
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Are you open to telehealth for parent training/caregiver support when appropriate?
Please Select
Yes
No
Maybe / want more info
Consent & Permission to Contact
*
“I give permission for Behavior Speaks ABA LLC to contact me and verify insurance benefits for my child.”
“I understand submitting this form does not guarantee immediate placement and I will be contacted regarding next steps.”
Submit
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