SpecResults ABA Services – New Client Intake

SpecResults ABA Services – New Client Intake

Please fill out the form to help us understand your child's needs and schedule an intake meeting.
Parent / Guardian Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Method of Contact
Child's Name

First NameLast Name
Gender
Primary Language Spoken at Home
School or Daycare (if applicable)
Current Grade
Insurance Provider
Member ID
Policy Holder Name
Relationship to Child
Upload Insurance Card (Front and Back)

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Has your child been diagnosed with Autism Spectrum Disorder?
Upload Autism Diagnostic Report

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Does your child currently have an IEP?
Upload IEP (if applicable)

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Which services are you interested in?
Please briefly describe your child’s strengths, challenges, or goals for therapy
I understand that submitting this form does not guarantee services.

I agree
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