Babies in Playroom

Applied Behavior Analysis (ABA) Service Request Form

Applied Behavior Analysis (ABA) Service Request Form

Please submit completed ABA Request form and accompanying documentation (copy of ID of guardian or guardianship documentation, diagnostic report, referral or script recommending ABA therapy, Letter of Medical Necessity from Pediatrician, and a copy of the front and back of ALL insurance card(s)) by encrypted email or fax to:

Info@ZOeABA.com    Fax: 706-780-1705

DOES S/HE HAVE AN IEP (PROVIDE COPY)?
AVAILABILITY FOR SERVICES: *INITIALLY MINIMUM OF 10 HOURS OF SERVICES ARE REQUIRED UNLESS BCBA DETERMINES LESS ARE NEEDED FOR MOST EFFECTIVE TREATMENT.
BEST TIME

PREFERRED LOCATION FOR ONGOING SERVICES:   *NOTE: UPON THE RESULTS OF ASSESSMENT, THE BEHAVIOR ANALYST WILL DETERMINE BEST LOCATION FOR SERVICES. 

Caregiver Signature:

Phone: 1-888-ZOeABA8

Fax: 706-780-1705

1110 13th Street, Suite D, Columbus, GA United States 31901

4651 Salisbury Road, Suite 400, Jacksonville, FL United States 32256
www.ZOeABA.com

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