Get Started Now!Let us know more about your child to start ABA services ASAP! (Fields marked with * are required.) Name * First Name Last Name Phone * (###) ### #### Email * Child's Birth Date * MM DD YYYY Child's Gender * Male Female Parent / Guardian Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Current Medical Necessity Criteria Information Has your child received a current and valid referral (12 months from the date it is signed by MD)? * The ordering MD provider type must be an approved medical provider. Yes No Has your child had a current comprehensive diagnostic evaluation (CDE)? * Yes No If yes, please specify which evaluation: Individualized Education Program (IEP). Evaluation by the recipient’s school district that has determined eligibility for special education. Diagnostic evaluation conducted by one of the following: Developmental pediatrician, clinical psychologist, or child and adolescent psychiatrist. Prior ABA Services Has your child received ABA services in the past and/or currently receiving ABA services? * Yes No If yes, please specify: The name of the agency your child previously received services from and/or is currently receiving services from. Has your child had a functional behavior assessment (FBA)? * Yes No If yes, please specify: * WHEN the functional behavior assessment was completed and WHO performed the FBA. Availability What location are you interested in receiving ABA services? * Home School Both What is your availability for receiving ABA services? * Please select as many time frames as apply. Morning (8am-12pm) Mid-day (12pm-3pm) Late day (3pm-6pm) Evening (6pm-8pm) Please add any additional relevant information that you would like to share. Insurance Information Insurance Company Provider * Insurance ID Number * Child's Name on Insurance Card * We will reach out to you shortly to upload required medical necessity information to get started. Thank you from Happy Luna ABA Services.
