Thank you for your interest in Little Adventures ABA, powered by DDSi!Our program provides individualized Applied Behavior Analysis (ABA) services for children and families across Indiana. Please complete this form so our team can learn more about your child, insurance coverage, and service needs.A member of our team will contact you shortly after submission.
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Grandparent
Legal Guardian
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Text Message
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Child's Age
*
Diagnosis or Reason for Seeking ABA Services
*
Current Services or Therapies (if any)
Preferred Service Location or Setting
Home
Clinic
School
Community
Other
Availability (Days/Times)
*
Insurance Provider
*
Insurance Plan Name
Member/Subscriber ID
*
Group Number
Policy Holder Full Name
*
First Name
Last Name
Policy Holder Date of Birth
*
-
Month
-
Day
Year
Date
Is the child covered under this policy?
*
Yes
No
Do you have secondary insurance?
*
Yes
No
Upload a copy/photo of your insurance card (front and back if possible)
Upload a File
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Best Time to Contact
Additional Notes or Questions
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