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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. Required
BEST TIME

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

Thanks for submitting! We will get back to you shortly.

Phone: 1-888-ZOeABA8

Fax: 706-780-1705

By opting in to receive SMS messages, you agree to the following: receiveSMS messages from [Zoe ABA] to provide updates and important
information. Message frequency may vary, and message and data ratesmay apply. You can opt out anytime by replying STOP. For help or moreinformation, reply HELP.
- **Opt-In** – Consent is obtained before sending messages. Subscribers will receive a confirmation message upon opting in:
  "You have successfully been subscribed to messages from [Zoe ABA] from this number. Message frequency may vary. Message and D at a
Rates may apply. Reply HELP for help. Reply STOP to unsubscribe."- **Opt-Out** – Reply STOP at any time to unsubscribe. You will receive aconfirmation message:
  "You have now been opted-out and will receive no further messages from[Zoe Pediatrics] from this number. Reply START to resubscribe."- **Help** – Reply HELP for assistance. You will receive:
  "For additional information, please call [Zoe ABA] at [1-888-ZOeABA8
]. To opt-out, reply STOP."- **Privacy** – Your information is used only for the stated purposes. See our full Privacy Policy on our website.

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