Socially Significant ABA

Intake Checklist

Thank you for your interest in Socially Significant ABA, an Applied Behavior Analysis agency. The first step in the process for obtaining ABA services with our agency is completing the “New Client” paperwork. We request that all new clients complete the Parent Questionnaire as well as the Release of Information document first and a packet will be sent with the welcome letter and all other forms. Additional documents may be needed depending on your child’s insurance information. For your convenience a list of all items needed to begin services is listed below. If you have any questions about the documents required or if you need assistance, please reach out to Austen Owens M.A. President/ Owner at aowensaba@sociallysignificantaba.com

Completed Parent Questionnaire
Completed Release of Information
Signed welcome letter
Signed Caregiver Responsibilities Form
Copy of client’s insurance card (front and back)
Proof of client’s medical diagnosis
Physician’s script for ABA assessment and treatment (must have the child’s name, DOB, ICD-10 code and state specifically “For ABA therapy”).

These documents can either be sent via email to aowensaba@sociallysignificantaba.com or via fax to (321) 428-8924. We look forward to receiving the completed documents!