ABA Services Waitlist Form

ABA Services Waitlist Form

Thank you for your interest in Color Outside the Lines ABA Co., LLC. We are currently accepting families for our ABA services waitlist. Completing this form does not guarantee immediate placement. Families will be contacted as openings become available based on service needs, locations, availability, and provider capacity. We appreciate your patience and look forward to connecting with your family.
Welcome to the ABA Services Waitlist! Please fill out this form to help us better understand your needs and match you with the right services. If you have any questions, contact us at danielle@cotl-aba.com.
Parent/Guardian Full Name

First NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Child's Full Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Date
Age
Gender of the Child
Current City
ZIP Code
Primary Diagnosis
Date of Diagnosis

MonthDayYear
Date
Who Completed the Diagnosis
Services Interested In

Other
Current Concerns
Goals for ABA Services
Is your child currently receiving ABA services?
Current ABA Provider
Reason for seeking a new provider
Is your child currently receiving other services?
Funding Type
Insurance Provider
Member ID
Group Number (if applicable)
Policy Holder's Name

First NameLast Name
Have you received the ABA authorization before?
Preferred Service Location
Preferred Days
Preferred Times
When are you hoping to begin services
Are you currently on another ABA waitlist?
Please share any additional information or questions.
Should be Empty: