CIAT Preliminary New Client Intake Form




Hello! Thank you for your interest in Compassion International ABA Therapy as your ABA provider. We are pleased to let you know we are assessing clients, you don't have to worry about a waitlisting list! Are you interested in ABA services? If you are interested, please share the information below to get started.

Timeline for Services:

Submit insurance documents to authorization team
Schedule assessment appointment with BCBA
Assessment Appointment
Assessment Documentation is submitted within 7 days of assessment appointment
Assessment Documentation is submitted to the insurance company
Insurance Companies takes 10-15 days to approve services
Once approved BCBA will coordinate  team meeting with family
Overall process is  between 4-6 weeks


Sign in to Google to save your progress. Learn more
Email *
Parent's Name *
Today's Date
MM
/
DD
/
YYYY
Client's Name *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Phone Number *
Address *
Residence *
Relationship to Client *
Language Preferences *
Insurance *
Insurance Policy Number *
Insurance Group Policy Number (if applicable):
Do you have a deductible?
Clear selection
Do you have Copay? *
Doctor Referral Letter *
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of ciabatherapy.com. Report Abuse
Google Forms