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