Type of Intake
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Please Select
Initial
Updated
Milestones ABA Intake Form
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Waitlist Notice
Due to the intensive, long-term nature of ABA services, our clinic maintains a managed waitlist to ensure requests reflect current needs and realistic service availability. Placement on the waitlist indicates interest in services but does not guarantee a start date. To keep our waitlist accurate and ethical, requests are periodically reviewed and may expire after 24 months if we are unable to confirm continued interest or if family circumstances, funding, or clinical needs have changed. Requests older than 24 months are considered inactive; however, families are always welcome to submit a new inquiry, which will be reviewed based on current capacity, clinical appropriateness, and funding considerations.
Instructions
Today's Date
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Month
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Day
Year
Date
Location Preference: Check all that apply
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Birmingham Office
Gulf Shores Office
Springville Office (Private funding Only; No insurance accepted)
Name of Patient
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First Name
Last Name
Name of Parent/Guardian
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First Name
Last Name
Parent/Guardian Email
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example@example.com
Patient's DOB
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Funding Source
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Insurance
Private Pay
(If you selected insurance, please complete the next two questions with policy information. If you selected private pay, please write N/A for both questions below.)
Insurance Provider
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(if you selected private pay above, write N/A)
Patient's Insurance ID or Contract Number
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(if you selected private pay above, write N/A)
Insurance Group Number
Insurance Card FRONT
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Insurance Card BACK
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Cancel
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Do you have Secondary Insurance? (A second insurance policy such as Medicaid
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Upload Secondary Insurance Card Photos
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Patient's Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Phone Number
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Area Code
Phone Number
Diagnoses ex; Autism, ADHD
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If no diagnosis, type N/A. Insurance will not cover ABA without a formal Autism diagnosis and report
What are your main concerns for your child and what would you like to achieve through therapy?
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Diagnosis Given By (MD, PhD, PsyD Name)
Diagnosis Date
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Month
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Day
Year
Date
Medical Doctor Name
Medical Doctor Practice Name
Medical Doctor Phone Number
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Area Code
Phone Number
Medical Doctor Fax Number
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Area Code
Phone Number
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone 1
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Area Code
Phone Number
Emergency Contact Phone 2
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Area Code
Phone Number
Medication and dosage
Other health concerns/diagnoses. Please note if your child experiences seizures. It is our policy to call parents or 911 if a child has a seizure at our office.
Parent/Legal Guardian Consent and Agreement for Emergencies: As parent/legal guardian, I give consent to have my child receive first aid by MBG staff, and, if necessary, be transported to receive emergency care. I understand that I will be responsible for all charges not covered by insurance. I agree to review and update this information whenever a change occurs and at least once a year.
Date of Signature
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Month
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Day
Year
Date
Name of School Currently Attending
Current Grade in School
Does your child have an IEP? Insurance companies require a copy of IEP with submission of treatment request. Please upload below
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Current Fees for Service
Private pay services are billed as follows. These rates apply to services which are not covered by Insurance and they apply to no/call no/show's and late cancellations.
Payment and Attendance Policies & Agreements
REQUIRED: By signing below, I am agreeing that I understand the fees for service chart above and will pay these rates when billed as a private pay client or an insurance client paying for no-call/no show fees or late cancellations, and I am agreeing to adhere to Milestones Policies on attendance.
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Copay & Deductible Payment Agreement
This Agreement is made effective on the date of signature, between Milestones Behavior Group, INC , located at 1280 Columbiana Road Suite 150, Birmingham, AL 35216 ("Provider") and the Patient. Patient agrees to pay all copayments and deductibles associated with healthcare services received from Provider. These services may include but are not limited to medical consultations, examinations, treatments, procedures, and any other services deemed necessary by Provider for Patient's healthcare needs.Copayments:Patient acknowledges that certain healthcare services may require copayments, which are predetermined fees set by Patient's insurance provider. Patient agrees to pay the applicable copayment at the time services are rendered, as outlined by Patient's insurance plan.Deductibles:Patient understands that deductibles are predetermined amounts set by Patient's insurance provider, which Patient must pay out-of-pocket before the insurance plan begins to cover certain healthcare expenses. Patient agrees to pay any deductibles associated with services received from Provider before insurance benefits are applied.Billing and Payment:Patient agrees to provide accurate insurance information to Provider and authorize Provider to bill Patient's insurance company for covered services. Patient understands that copayments and deductibles are Patient's responsibility and agrees to pay any outstanding balances not covered by insurance within the timeframe specified by Provider.Insurance Coverage:Patient acknowledges that insurance coverage and benefits are determined by Patient's insurance policy and may vary depending on the services received. Patient agrees to familiarize themselves with their insurance policy and to contact their insurance provider directly with any questions regarding coverage or benefits.Non-Covered Services:Patient acknowledges that certain services may not be covered by Patient's insurance plan, and Patient agrees to pay for any non-covered services in full at the time services are rendered.Financial Responsibility:Patient understands and agrees that they are financially responsible for all copayments, deductibles, and any other fees associated with healthcare services received from Provider, regardless of insurance coverage or benefit limitations.Agreement Termination:This Agreement shall remain in effect until terminated by either party upon written notice to the other party.Governing Law:This Agreement shall be governed by and construed in accordance with the laws of Alabama/Jefferson County.
Signature of Agreement
By signing below, you are agreeing to the terms above
Date of Signature
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Month
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Day
Year
Date
REQUIRED: INSURANCE- CONSENT FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR PAYMENT, TREATMENT, AND HEALTH CARE OPERATIONS Authorization to Release Information for Claims: I authorize the release of any medical or other information necessary to process claims submitted for services rendered to my child/family by Milestones Behavior Group, INC., and I authorize payment of medical benefits to Milestones Behavior Group, INC for their services.
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REQUIRED: Consent to Provide Therapeutic Services I am providing consent to receive Applied Behavior Analysis Services. I give consent for Milestones Behavior Group, Inc. to provide ABA services. I understand that I may request clarification, ask questions, and/or terminate services at any time.
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REQUIRED: Agreement to Participate in Parent Training: I agree to participate in ABA parent training for a minimum of one hour per month for each month that my child receives ABA services at Milestones.
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Consent for Media Release (optional): I give Milestones Behavior Group, Inc. permission to use my child, children, or individuals for whom I am legal guardian’s photograph and/or video in its promotional materials, and in training materials. I understand that the photograph and/or video may be used in publication, print ad, direct mail piece, electronic media (e.g., video, cd-rom, DVD, Internet, www), or other forms of promotion. I release Milestones Behavior Group, Inc. employees and designees from liability for any violation of any personal or proprietary right I may have in connection with such use. I am 18 years or age. I understand that this release is optional and will in no way affect the rendering of said services.
Attendance Policy
Two instances of No Call/No Show will result in the termination of services. Two instances of late cancellations will result in the termination of services.
REQUIRED: By signing below, you are agreeing to adhere to Milestones attendance policy.
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Date of Signature
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Month
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Day
Year
Date
Required File Uploads
Diagnostic Evaluation Report showing your child's diagnosis (ex; Autism F84.00), IEP from School if applicable, Insurance Card (front and back), Speech/OT Evaluations if applicable AND all sections in this form completed/signed. WE WILL NOT BE ABLE TO CONTACT YOU IF THESE DOCUMENTS ARE NOT UPLOADED. THEY ARE REQUIRED BY INSURANCE COMPANIES TO APPROVE and COVER PAYMENT FOR SERVICES. You may also email them to: therapy@milestonesaba.com
Diagnostic Evaluation Report if applicable
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Insurance will not cover ABA without a formal Autism diagnosis and report.
Cancel
of
Speech-Langage, Occupational Therapy, Physical Therapy and/or ABA Therapy Reports if applicable
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Cancel
of
Individualized Education Plan (IEP)
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Referral or Other Medical reports if applicable
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ABA Telehealth Services & Parent Training
For Office Use Only
DON'T FORGET TO REVIEW AND SIGN THE MBG PARENT HANDBOOK:
https://form.jotform.com/242064143972051
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