Initial ABA Intake Request

Contact Name*
First Last
Contact Phone*
Contact Email*
Relationship to Individual Needing Services:*
Best Time of Day to Reach Contact:*
Age of Individual Receiving Services:*
City in which in-home therapy will be provided:*
Diagnosis of Individual Receiving Services:
Desired Start Date:*
- Immediately
- 1-2 Months
- 3-5 Months
Desired Number of Hours per Week:*
- 2-15
- 16-30
- 31-40
Desired Availability (Please list preferred days/times of therapy sessions if known):
Do You Plan to Use Insurance to Cover the Cost of Services?*
- Yes
- No
How did you hear about Crosby Learning Solutions?*
Please let us know any other relevant information you wish to provide:
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Insurance Verification

Name*
First Last
Gender*
- Male
- Female
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Diagnosis:*
Insured Information: Parent, Guardian
Insurance Company*
Identification Number*
Group/Plan Number*
Employer
Policy Holder's Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender*
- Male
- Female
Email
Please list any other information, if applicable, that you feel would be helpful to us in this process:
Please email a photo of the front and back of your insurance card to office@crosbylearningsolutions.org
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