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Student Enrollment Form

Student/Caregiver Information

Does student have a medical ASD diagnosis?
If we can't reach you by phone, can we text you?
Days requesting services (Please choose at least *4 days a week minimum of 10 hours per week)
Where are you seeking ABA services?
Has your child received ABA previously?

Parent(s) / Legal Guardian Information

Primary Caregiver

Secondary Caregiver

Insurance Information

Relationship To Student
0 MB/18 MB
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Thank You!

Thank you for submitting your application to Achievement Behavior Services for ABA therapy. We appreciate your interest in our services and the trust you have placed in us to support your child's development.

We understand that finding the right ABA therapy services for your child can be overwhelming. Our friendly clinical team is committed to making this process as smooth as possible. Please allow us 24-48 hours to evaluate your application and verify benefits eligibility with your insurance provider.

Once we receive approval for benefits, we will promptly provide you with a status update. To proceed with the process, we kindly request the following documents:

  1. **Proof of Diagnosis (POD):** Please request a POD from your child's pediatrician specifying F84.0 DX ABA Therapy. You can fax or scan it to us at **516-329-9747**.
  2. **Diagnostic Reports:** We require all documents related to your child's autism diagnosis. These reports are essential for obtaining approval for ABA services.

If you do not have any diagnostic reports, we can refer you to a psychologist within our network who has availability and can expedite the evaluation without a long waiting period. This will ensure you have the necessary documentation to proceed with ABA therapy services for your child. If you would like to explore this option, please contact Esti or Julia at your earliest convenience at **516-229-1194 ext 207**. They will be more than happy to assist you and provide the necessary referral information.

Please do not hesitate to contact us by email or phone if you have any questions or concerns. We are here to support you and look forward to speaking with you soon.

Warmest Regards,

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