ABA Services

Client Intake Form

By completing this form, you are indicating an interest in our services, and giving us consent to verify insurance eligibility for our services. Our goal is to be in touch with you within 24 hours after we receive your information.

Please call our office at 325-530-4089 for more assistance.

Parent/Guardian Name

Parent/Guardian Contact Number

Name list else

Child's Name

Child's Date of Birth

Does your child have an autism diagnosis?

Please list any additional diagnosis of individual requiring services

Will insurance be billed for services?

Insurance ID and Group Number (Please upload a front and back copy of your card below)

Insurance Card Copy

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Is there anything else you would like us to know, or questions we can answer?

How did you hear about us?

Are you inquiring about services in the Abilene area?

Checkboxes

Applied Behavior Analysis Provider

Phone Number: 325-530-4089
Email: tcmiller@behavioralfocus.net

We're Open!

Mon	09:00 am – 06:00 pm
Tue	08:00 am – 06:00 pm
Wed	08:00 am – 06:00 pm
Thu	08:00 am – 06:00 pm
Fri	08:00 am – 06:00 pm
Sat	By Appointment
Sun	Closed

Client Intake Form

Applied Behavior Analysis Provider

We're Open!

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