ABA Service Request

Ready to get started with ABA Access Academy Behavioral Therapy?

Fill out the service request form

ABA Access Academy accepts new clients from 1-18 years of age and requires a commitment of a minimum of 4 therapy sessions per week, which is approximately 10 hours of therapy.

This form is secure and HIPAA compliant so your information will stay safe. If you have any questions or concerns, email us at admin@abaaccess.com or call at 971-202-0058.



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Email: *
Child's Name:
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Child's Birthday:


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Parent/Guardian(s) Name(s):


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Phone Number:
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Address:
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Does the child have an autism diagnosis?
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Does the client have any additional diagnosis? If yes, please indicate them.


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Please indicate which insurance provider your child has:


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What is the member number for the insurance plan?


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What is the name of the subscriber for the insurance plan?


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Does your child have Secondary Insurance?


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