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Services
ABA Explained
Our Approach
Events
About Us
Contact
Career
Appointment
Enrollment
Home
Services
ABA Explained
Our Approach
Events
About Us
Contact
Career
Home
Services
ABA Explained
Our Approach
Events
About Us
Contact
Career
Enrollment
CURRENTLY ACCEPTING
PRIVATE PAY & THE FOLLOWING INSURANCE:
Enrollment Form
Flexible Payment Plan
"
*
" indicates required fields
1
Contact Information
2
Child Information
3
Additional Information
4
Additional Files
PARENT/GUARDIAN FIRST NAME
*
PARENT/GUARDIAN LAST NAME
*
PRIMARY EMAIL
*
CELL PHONE
*
ADDRESS - LINE 1
ADDRESS - LINE 2
CITY
STATE
ZIP/POSTAL CODE
FIRST NAME
*
LAST NAME
*
BIRTH DATE
MM slash DD slash YYYY
GENDER
*
Male
Female
Non-Binary
Prefer not say
CURRENT INSURANCE
BCBS
BCBS - Medicaid
Cigna
Aetna
Community Health Choice - Marketplace
Community Health Choice - Medicaid
Tricare
Magellan
Wellpoint
Superior Health Plans
Compsych
Molina Marketplace
INSURANCE BENEFITS AND ELIGIBILITY RELEASE OF INFORMATION
Yes
No
"Yes" I allow Rising Stars ABA to contact my insurance provider for a B&E check
CURRENT INSURANCE
Mon
Tue
Wed
Thu
Fri
Sat
Sun
DOES YOUR CHILD HAVE A MEDICAL DIAGNOSIS OF AUTISM?
Yes
No
IF YES, PLEASE PROVIDE DIAGNOSIS
*
INSURANCE SUBSCRIBER'S NAME
*
INSURANCE SUBSCRIBER'S DATE OF BIRTH
MM slash DD slash YYYY
HOW DOES YOUR CHILD COMMUNICATE?
*
Spoken Words
Sign Language
Use of a Communication Device
Non-Verbal
DOES YOUR CHILD ENGAGE IN ANY BEHAVIORS OF CONCERN?
Yes
No
DO YOU HAVE ANY CONCERNS REGARDING FEEDING?
Yes
No
HOW DID YOU HEAR ABOUT US?
Web Search (Google or other)
Social Media
Referral from Primary Healthcare Provider
Referral from Diagnostic Evaluation Provider Referral from Speech or OT Provider
Referral from Insurance Company
Client Referral
Event Communication
Employee Referral
DIAGNOSTIC (DX) EVALUATION (accepted file formats: .doc, .docx, .pdf | max: 10mb)
Max. file size: 490 MB.
INSURANCE CARD (FRONT) (accepted file formats: .doc, .docx, .pdf | max: 10mb)
Max. file size: 490 MB.
INSURANCE CARD (BACK) (accepted file formats: .doc, .docx, .pdf | max: 10mb)
Max. file size: 490 MB.
