ABA Service Request

Ready to get started with ABA Access Academy Behavioral Therapy?

Fill out the service request form

ABA Access Academy accepts new clients from 1-18 years of age and requires a commitment of a minimum of 80% of the BCBA's prescription.

This form is secure and HIPAA compliant so your information will stay safe. If you have any questions or concerns, email us at admin@abaaccess.com or call at 971-202-0058.



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Email: *
Child's Name:
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Child's Birthday:


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DD
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YYYY

Parent/Guardian(s) Name(s):


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Phone Number:
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Address:
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Does the child have an autism diagnosis?
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Does the client have any additional diagnosis? If yes, please indicate them.


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Please indicate which insurance provider your child has:


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What is the member number for the insurance plan?


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What is the name of the subscriber for the insurance plan?


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Does your child have Secondary Insurance?


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