ABA Service Inquiry Caregiver Form   
This form is the first step in the assessment process for your loved one at Clear ABA. Your input is crucial for us to understand their needs fully. Please take your time and provide as much information as possible to ensure we can tailor our services effectively.
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Phone Number  *
Email *
Currently we are only taking Medicaid clients. Do you have Medicaid? *
Medical Record Number *
Name of Child  *
Child's Birthday  *
MM
/
DD
/
YYYY
Caregiver Name(s)? *
Address? *
Relationship to client *
Required
Is the child under 21? *
Does He or She have a diagnosis of Autism Spectrum Disorder (ASD) by a Qualified Health Care Professional (QHCP) (Pediatrician, Psychologist, Medical Doctor)? *
Comprehensive Diagnostic Evaluation (CDE) completed by a QHCP? *
Do you have an ABA referral completed by a QHCP dated within the past 6 months?
 *
Has your child received ABA services before ? *
If yes, which ABA company or clinic and for how long? (If no, please answer N/A) *
Do you have an active authorization with another ABA company? *
If yes, why did service end? (If no, please put N/A) *
Which areas does your child need help with? *
Required
Where do you want ABA services to take place? *
Required
Does your child receive any of these services? *
Required
His or Her School placement/schedule of academic activities *
Does he or she take any medication? if so what is the name of the medication and what is it for?  (If no, please answer N/A) *
How soon are you looking for ABA services ? *
What are your desired outcomes from using ABA services?
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