ABA Therapy Registration – RealPath Behavioral Services d/b/a RealPath ABA

ABA Therapy Registration – RealPath Behavioral Services d/b/a RealPath ABA

Thank you for choosing RealPath ABA. Please complete this short registration form so our team can review your child’s needs, insurance benefits, and next steps. Completing this form does not guarantee admission or insurance authorization.
Child Information
Legal First Name
Legal Last Name
Middle Name
Preferred Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex Assigned at Birth
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
ZIP Code
Primary Language
Race
Ethnicity
School/Daycare Name
Current Grade
Preferred Service Setting
Preferred Service Area/Location
Please enter your city or service location.
Parent / Legal Guardian
Parent / Legal Guardian Full Name

First NameMiddle NameLast Name
Relationship to Child
Are you legally authorized to consent to services for this child?
If you answered No, contact RealPath ABA before submitting.
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Second Parent/Guardian Name

First NameMiddle NameLast Name
Second Parent/Guardian Phone
Please enter a valid phone number.Format: (000) 000-0000.
Best Time to Contact
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Relationship to Child
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Clinical and Referral Information
Autism diagnosis
What support are you seeking?
Is the child currently receiving ABA therapy?
Has the child received ABA therapy before?
Diagnosing provider or facility
Diagnosis date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Level of ASD
Medications
Comorbid Diagnosis
Other current services
Safety or urgent concerns
Upload diagnostic evaluation

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Insurance
Clear photos are accepted. Please make sure all text on the card is visible.
Primary insurance company
Policyholder name

First NameMiddle NameLast Name
Policyholder date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to child
Member ID
Upload front of primary insurance card

Cancelof
Upload back of primary insurance card

Cancelof
Does the child have secondary insurance?
- Acknowledgments and Signature
- I certify that the information provided is accurate to the best of my knowledge.
- I authorize RealPath Behavioral Services d/b/a RealPath ABA to contact me regarding registration, benefits verification, scheduling, and services.
- I authorize RealPath ABA to verify insurance benefits and obtain information needed to determine eligibility and request authorization. I understand that verification is not a guarantee of payment or coverage.
- I understand this registration form does not establish a provider-patient relationship or guarantee acceptance into services.
- I acknowledge receipt or availability of the Notice of Privacy Practices.
- Notice of Privacy Practices
- Communication preferences and consent:
- Parent / Legal Guardian printed name
  
  First NameMiddle NameLast Name
- Parent / Legal Guardian electronic signature
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Realpath ABA Inc would like your consent to send informational text message communications from +18555975022 to your mobile number listed above, in response to your questions or to provide information relevant to your relationship with us. Consent is not a condition of purchase. Message frequency varies. Message and data rates may apply. Reply 'STOP' to unsubscribe at any time. Reply 'HELP' for assistance or more information. We do not share your mobile opt-in information with anyone. See our privacy policy and messaging terms and conditions available by request for more information.
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ABA Therapy Registration – RealPath Behavioral Services d/b/a RealPath ABA

Child Information

Parent / Legal Guardian

Clinical and Referral Information

Insurance

Acknowledgments and Signature