Behavior Blossoms ABA Services Form (Medicaid Clients)
Thank you for contacting Behavior Blossoms LLC for your behavior therapy needs. We look forward to serving you and assisting your child to blossom.

 *Please note all services are subject to staff availability and we currently have a waiting list for after school hours and in certain counties. 

We will need a few pieces of information and documents in order to move the intake process forward:

1. Doctors Referral (no electronic signatures, must include client DOB, diagnosis and the recommendation that behavior analysis services are medically necessary. Dr. must be a medicaid provider) Valid for 1 year.

2. Diagnostic Report or Evidence of Behaviors (documented by Child Psychologist, Child Psychiatrist or Developmental Pediatrician ONLY, OR School county Evaluations or IEPs (Individualized Education Plans)

3. Copy of patient ID and/or both sides of insurance card.

These pieces of information may also be helpful to submit at this time if possible, but may be completed at the time of assessment. 

4. Signed Consent Form (available here ---> https://drive.google.com/open?id=11qJ95OgUCxjbHcFjbIPrb3gmVHDYOrlZ)

5. Prior medical assessments, IEPs, evaluations and therapy records may also be submitted at this time.

6. Intake form   (available here ---> https://drive.google.com/open?id=1DuWM_x2XdPJryXigvNYPcDXHIfDTd_GV)


After these things are completed, we will discuss any wait times that may be experienced. Once we have staffing, we will seek an authorization for an initial assessment.

Email address *
Child's Name *
First and last name
Parent's Name *
First and last name
Parent's phone number *
Is your child receiving ABA from another provider? *
Are you willing to participate in parent training that is mandatory for funding sources and progress? *
Location of desired services (please specify city and setting) *
Availability (hours and days) *Please note if any changes to availability are made or requested after submitting this form, you may be placed on the waiting list for accommodation. *
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