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ABA Services Intake Form

This form is required for those seeking ABA services from Mr. L's Tutoring and Enrichment. AT (Associate Tutors) will be assigned to your case based on availability and proximity. This intake will provide us the information needed to confirm eligibility for these services through your insurance. NOTE It is the client's responsibility to alert the company of any changes in insurance coverage. The client is responsible for services not covered by insurance for any reason.

First name

Last name

Person receiving services First and Last Name

Phone

Address

Please list all of your medical conditions & diagnoses

Have you worked with any ABA company before? What goals did they have for your child?

Insurance Company

Full name of insured party

Date of birth of Insured Party

Date of birth of Recipient of services

Insurance ID Number

Insurance Group #

PDF of ASD Diagnosis

Front of Insurance card for Recipient

Back of Insurance card for Recipient

How did you hear about us?

By signing this document, I acknowledge the information provided is factual and accurate. I hereby waive and release the business, its owners, and its staff from any and all liability, past, present, and future, relating to the services provided.

Signature

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