ABA Service Request Form

ABA Service Request Form

In order for us to better assist you accessing treatment services; please fill out the following ABA service request form. If questions (or sections) do not apply to you and/or your child, please select "N/A".
Parent Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Please indicate your preferred method of contact:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Child Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Diagnosis
Diagnostic Provider
Gender
Primary Care Physician
Primary Care Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Practice Name
What are the primary reasons for seeking ABA services?
Primary Insurance Information
In order for us to verify that your insurance covers ABA services for your child, we will need this information. Additionally, please email a copy of your insurance card (front and back) to the office at hamricka@lifeworksautism.org
Insurance Carrier
Policy Holders Employer
Policy Holder Name
Relationship to Child
Policy Holders Date of Birth

MonthDayYear
Date
Policy Number
Group Number
Effective Date of Policy

MonthDayYear
Date
ProviderCustomer Service Phone Number
Format: (000) 000-0000.
Secondary Insurance Information
If you have secondary insurance, please complete the following section. Additionally, please email a copy of your insurance card (front and back) to the office at hamricka@lifeworksautism.org
Do you have Secondary Insurance?
Insurance Carrier
Policy Holders Employer
Policy Holder Name
Relationship to Child
Policy Holders Date of Birth

MonthDayYear
Date
Policy Number
Group Number
Effective Date of Policy

MonthDayYear
Date
ProviderCustomer Service Phone Number
Format: (000) 000-0000.
Other Therapy Services
Please list any other services that your child is receiving. If your child is not yet receiving these services, or if they are not applicable, please leave that section blank.
Is your child receiving other therapy services?
Other Types of Therapy
Speech Therapy
Company Name
SLP Name
Number of Hours per/week
Therapy Days - Time
How long has your child been receiving speech services with this provider
Occupational Therapy (OT)
Company Name
OT Name
Number of Hours per/week
Therapy Days - Time
How long has your child been receiving OT services with this provider
Physical Therapy (PT)
Company Name
PT Name
Number of Hours per/week
Therapy Days - Time
How long has your child been receiving PT services with this provider
Early Intervention Services (ages 0-3 years)
Company Name
Therapist Name(s)
Number of Hours per/week
Therapy Days - Time
How long has your child been receiving early intervention services with this provider
Educational Placement
Is your child attending daycare, preschool or school?
Daycare or School Name
Address
Phone Number
Format: (000) 000-0000.
Director's Name
Classroom Teacher's Name
Days and times that your child attends
Is the daycare or school open to having ABA therapists come onsite?
Availability
Please indicate when your child is available for ABA services. If your child is currently receiving other services (e.g., OT, SLP, etc) please also indicate that on the chart below. If your child is still taking naps, please indicate that as well.

Rows	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
8:00 am
8:30 am
9:00 am
9:30 am
10:00 am
10:30 am
11:00 am
11:30 am
12:00 pm
12:30 pm
01:00 pm
01:30 pm
02:00 pm
02:30 pm
03:00 pm
03:30 pm
04:00 pm
04:30 pm
05:00 pm
05:30 pm
06:00 pm
06:30 pm
07:00 pm

Should be Empty:

Parent Information

Child Information

Primary Insurance Information

Secondary Insurance Information

Other Therapy Services

Speech Therapy

Occupational Therapy (OT)

Physical Therapy (PT)

Early Intervention Services (ages 0-3 years)

Educational Placement

Availability