(818) 330-5328

    Student Name

    Date of Birth


    Students address

    Street Address Line 2



    Postal / Zip Code

    Does student have a medical ASD diagnosis?

    Responsible Caregiver Name

    Phone Number


    #2 Responsible Caregiver Name

    #2 Caregiver Phone Number

    Name of Prescribing Physician

    Dr. Phone Number

    Hours available for ABA services (*10 hour minimum required)

    Days Requesting Services (*4 days a week required)

    Referred by (allow us to thank them)
    [radio* referred-by use_label_element default:1 "Physician" "Google/Internet Search" "Friend" "Esti/ Intake Coordinator" "Other"]

    Preferred method of contact

    Additional comments that you feel we should know

    Please provide us with any relevant information that you may feel is important

    Insurance Information

    please provide us with primary and secondary insurance information (almost done)

    Primary person Policyholder

    Relationship to Student
    [radio* RelationshiptoStudent use_label_element default:1 "Mother" "Father" "Self" "Otehr"]

    Policyholder DOB

    #1 Primary Insurance Provider

    OTHER insurance if not listed above

    Group Number primary

    Insurance Phone Number


    #2 Insurance Provider

    #2 Insurance ID number

    #2 Insurance Phone Number

    Snap or upload photo of front of insurance card

    Snap or upload photo of back of insurance card

    Consent Signature

    Thank you for your application we will contact you within the next 24 hours.

    b>IMPORTANT: Before we can verify your coverage with your insurance company, we need a copy of the front and back of your insurance card. Please scan or snap a picture of both sides and submit them here or email info@ahappyfam.com If you require assistance, please call us at 818-330-5328 or email us.

    A quote of benefits and/or authorization does not guarantee payment. Payment of benefits is subject to all terms, conditions, limitations, and exclusions of the member's contract at the time of service**you will always be solely responsible for letting your provider know about changes in insurance and/or payment status of services. Any services not fully. covered by insurance will be the responsibility of the patient/ family, caregiver

    Privacy Disclaimer Achievement Behavior will never sell your information to any third-party person we are committed to protecting your personal information and your right to privacy, please contact us at info@ahappyfam.com if you have any questions

    Privacy guarantee: We do not share your information and will contact you only as needed to provide our ABA service.

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