Jade ABA Therapy

Quick and simple ABA Services intake form for your needs

INTAKE FORM

Apply for Services.

Please use the Intake Form below to help us learn about your needs. Our staff will follow up with any questions within 48 hours. Services are available on a first-come, first-served basis and by therapist availability in your location.

Dive into JADE ABA progress! Our form’s a bit longer than a tweet, but every detail counts for personalized care.  Ready, set, let’s pave the way to success together!

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Patient Information

Please fill in the form below.

"*" indicates required fields

Name*
Address*
Address

Contact Information

MM slash DD slash YYYY
Gender
Name

Days and Hours Desired for ABA Services

Minimum 10 Hours Required

Sundays*
Mondays*
Tuesdays*
Wednesdays*
Thursdays*
Fridays*
Saturdays*
Name of Insured | Policy Holder*
MM slash DD slash YYYY
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 32 MB.
    Please upload an image of the FRONT of your Insurance Card.
    Drop files here or
    Accepted file types: jpg, gif, png, pdf, Max. file size: 32 MB.
      Please upload an image of the BACK of your Insurance Card.
      Drop files here or
      Accepted file types: jpg, gif, png, pdf, Max. file size: 32 MB.
        Please upload a copy of your Autism DIAGNOSIS or IEP
        Drop files here or
        Accepted file types: jpg, gif, png, pdf, Max. file size: 32 MB.

          Emergency Contact Information

          Name*

          HIPAA Acknowledgement

          I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health insurance portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize Jade ABA in the HIPAA Acknowledgement. to use and disclose my protected health information to carry out: Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment) Obtaining payment from third-party payers (e.g. my insurance company) The day-to-day healthcare operations of Jade ABA in the HIPAA Acknowledgement. I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact Jade ABA in the HIPAA Acknowledgement. at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
          I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health insurance portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize Jade ABA in the HIPAA Acknowledgement. to use and disclose my protected health information to carry out: Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment) Obtaining payment from third-party payers (e.g. my insurance company) The day-to-day healthcare operations of Jade ABA in the HIPAA Acknowledgement. I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact Jade ABA in the HIPAA Acknowledgement. at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
          Hidden
          Patient Name*
          MM slash DD slash YYYY
          This field is for validation purposes and should be left unchanged.

          Get In Touch

          Phone: (410) 616-0901
          Email: info@jadeaba.org

          Quick Links

          Contact

          For more information, feel free to contact us.
          Phone number: (410) 616-0901

          For more information, feel free to contact us.
          Phone number: (410) 616-0901

          This field is for validation purposes and should be left unchanged.
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