Request Form- Behavior Analysis Services

Behavior Analysis Services Request

To be completed by parent or caregiver
Date*

MonthDayYear
Date
Contacted
How did you hear about us?*
How did you hear about us? Please specify:*
Ex: Doctor's name, therapist's name, school, individual, internet search
Child's name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*
Child's Age*
Insurance Provider*
Select your insurance provider from the list of plans with which we are in network:*
Child's SSN*
County where child resides*
Child's Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Name of Child's School
Location of Child's School*
City, State
Child Resides with*
Parent/Caregiver Name*

First NameLast Name
Parent/Caregive Phone #*

Area CodePhone Number
Parent/Caregiver Email*
example@example.com
List other service providers, including name, agency and contact phone numbers
Child's Primary Care Physician*
Child’s Diagnosis*
Referral source name, phone, email*
Reason for referral*
Behaviors of concern*
Where will services be needed? Check all that apply.*

SchoolHomeSocial Skills GroupOther
Insurance will not accept photos of documents.

Please upload any of the following required information that you have on hand:
- Referral for ABA Therapy
- Insurance card
- Comprehensive Diagnostic Evaluation
- IEP if your child has one
Files may also be emailed separately to info@potpba.com
Upload any required documentation here:

Browse Files

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Notes
Should be Empty:

Behavior Analysis Services Request