How do I enroll my autistic child in therapy

Did you obtain parental consent to share this information with All Aboard ABA?

Yes

No

Recommending ABA Services to Address

Challenging behavior issues/excesses

Language/communication deficits

Social deficits

Potty training

Feeding/eating/swallowing issues

Diagnosis of Autism given?

Yes

No

If yes, please select level of Autism

Mild

Moderate

Severe

Diagnosis Comments

Primary Insurance

Insurance Type

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Patient Details

Patient’s Name

DOB

City

Zip Code

Parent/Guardian Contact Information

Parent’s Full Name

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Email Address

Referring Physician Details

Physician Name

Organization/Practice Name

Address Line 1

Address Line 2

City

State

Zip Code

Office Phone Number

Office Fax Number

Office Email

Supporting Documentation Checklist

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The patient’s comprehensive diagnostic evaluation includes standardized testing and scores signed by a Physician (MD/DO) or a Clinical Psychologist.

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A referral for ABA Therapy that is signed by a Physician and includes a diagnosis code for Autism Spectrum Disorders (F84.0).

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I will fax the patient’s comprehensive diagnostic evaluation and referral for ABA therapy directly to All Aboard ABA.

Diagnostic Evaluation (.doc, docx, .pdf)

Maximum file size: 15MB

Referral for ABA Therapy (.doc, docx, .pdf)

Maximum file size: 15MB

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Physician Referral for ABA Services

Primary Insurance

Patient Details

Parent/Guardian Contact Information

Referring Physician Details

Supporting Documentation Checklist

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