ABA Therapy | Stepping Stones Behavioral Services |ASD

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What do we need to get started?

A written referral with the child’s diagnosis stating ABA evaluation and treatment is required.

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Child’s Information

Child’s Information

First Name

Last Name

DOB

Gender

Diagnosis

Current insurance

Primary Care Physician

Setting where services will be rendered

Home

School/Daycare

Community

Other

Has the child receive ABA services before?

Yes

How did you get to know us?

Parent’s or Legal Guardian’s Information

Texto libre

Parent/Guardian 1:

First Name

Last Name

Address , City, State, Zip Code

City

State

Zip Code

Phone Number

Marital Status

Parent/Guardian 2

Parent/Guardian 2:

First Name

Last Name

Address

City

State

Zip Code

Phone Number

Marital Status

Attachments

Attachments (Click on each one to upload a file)

Doctor’s referral/prescription

*Doctor’s referral/prescription

Insurance card front

*Insurance card front

-Insurance card back

*Insurance card back

Neuro/Comprehensive Psychological Evaluation

*Neuro/Comprehensive Psychological Evaluation

IEP (Individualized educational plan) if applies

*IEP (Individualized educational plan) if applies

Additional Evaluations (e.g., speech, occupational, previous behavior plans)

Parent Driver’s License/ID

*Parent Driver’s License/ID

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What do we need to get started?

Request Services

Hours of operation

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