top of page
White-01.png

Miami Behavior Institute Service Request Form

To request ABA services for your child, please complete this form with all required information. This helps us understand your needs and ensures we can begin the process of coordinating care.

Client Information

Birthday
Month
Day
Year
Has the child received ABA services in the last 6 months?
Yes
No
What type of services are you looking for?

Please note: While we do everything we can to accommodate your preference, the final decision on the service setting is determined by clinical need—whether it is appropriate to provide services in the requested setting—and insurance authorization, as some insurance plans have limitations on where services can be delivered. Our team can go over specific details with you upon starting services.

Parent/Guardian Details

Multi-line address

Insurance Information

Do you have insurance under Medicaid?
Yes
No
Do you have a private insurance?
Yes
No
Do you want to request private pay or EMA Scholarship options for your ABA services?
Yes
No

Consent

Electronic Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
bottom of page