We're Accepting New Clients!

Intake Process

Intake

A consultant will retrieve your insurance information and diagnostic report to begin authorization.

Individualized Assessment

A BCBA (Board Certified Behavior Analyst) will assess the needs of your child and create a personalized treatment plan for ABA therapy.

Direct Treatment

We will pair your child with a therapist who will best accommodate your availability and needs. The therapist will collect data on the individualized treatment plan that is created by a BCBA. Your child will receive consistent supervision and regular parent consults to ensure high-quality service.

Intake

A consultant will retrieve your insurance information and diagnostic report to begin authorization.

Individualized Assessment

A BCBA will assess the needs of your child and create a personalized treatment plan.

Direct Treatment

REQUEST TO ENROLL BELOW

Start by filling out the information below and attaching all necessary documents.

Now Accepting:

NJ Health, Horizon, Aetna & EverNorth/Cigna

Serving New Jersey

*PLEASE ATTACH THE FRONT AND BACK OF YOUR INSURANCE CARD, DIAGNOSTIC REPORT/ABA PRESCRIPTION (ALL PAGES)

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Name of Person Completing Form

Date Completed

Child's Full Name

Child's Full Address

Child's Date of Birth

Child's Gender Identity:

Male

Female

Primary Caregiver/ Parent's Full Name

Primary Caregiver/ Parent's Email

Primary Caregiver/ Parent's Phone Number

Additional Caregiver/ Parent's Name

Additional Caregiver/ Parent's Email

Additional Caregiver/ Parent's Phone Number

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Healthcare Information

Primary Healthcare Insurance

Health Plan Member ID

Policy Group Number

Policyholder's Name (Primary)

Policyholder's Date of Birth

Front Image of Insurance Card

Upload File

Back Image of Insurance Card

Upload File

Secondary Insurance

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Medical History

Primary Care Provider

Primary Care Provider Provider Phone Number

Name of ASD Diagnosing Provider

Hospital/ Clinic Name

Date of ASD Diagnosis

Diagnosed Level of ASD:

Please list any additional diagnoses or medical conditions:

Diagnosing Information: To receive ABA services, a referral/prescription for Applied Behavior Analysis is required, accompanied by a diagnosis of Autism Spectrum Disorder and a comprehensive evaluation from a qualified specialist. Whether you choose to upload these documents now or submit them later, please note that we cannot advance your PDF application until we have received these essential documents.

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Legal Guardianship and Consent

List which guardian or parent(s) have legal authority to make medical decisions for this child:

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ABA Services

Are you willing to participate in a weekly or monthly Family Guidance/Parent Training session, which might be scheduled outside of the standard therapy hours?

Yes

Is your child currently enrolled in services with another ABA provider?

Yes

If yes, please provide the name:

What are your primary areas of concern regarding your child’s ASD diagnosis?

Please share any extra detail that may aid in setting up services for your child.

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Availability for Services

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Field label

I acknowledge that I have the option to request a copy of this form in a different language.

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For assistance, I can contact info@lifelineaba.com

Embark on the path to progress with Lifeline ABA. To begin personalized ABA therapy for Autism Spectrum Disorder, reach out today. Ready to get started? Call us at (914) 517-3826 to schedule a consultation and take the first step toward positive change

We're Accepting New Clients!

Intake Process

REQUEST TO ENROLL BELOW

Now Accepting:

Serving New Jersey

Contact Us

SERVICE AREAS