Step 1 of 6
1

Client Information

This is the person who will be receiving services

Required
Required
Required
Required Invalid date. Date of birth can not be future date.
Required
Required
Has the client received ABA services in the past year?
Yes
No
Required
 
Step 2 of 6
2

Parent/Guardian Information

Parent details

Required Invalid Email

It looks like you’ve already applied for services. Please log in to your client portal to: access/upload new documents or request services for another child/individual. If you have any questions, please use our chat bot.

Required
Middle Name
Required
Required Invalid date of birth. Age must be more than 18 years. Date of birth can not be future date.
 

Required
Required
Required Invalid zip.
Required
Required

Required Invalid Phone number
Invalid Phone number
Invalid Phone number
By providing your mobile phone number, you agree to opt-in to receive PBS Notifications text messages. Message frequency varies per user. Message and data rates may apply. Text STOP to opt out or HELP for help.

Used only for internal communications & billing purpose

 

Parent/Guardian Information II

Parent details II

It looks like you’ve already applied for services. Please log in to your client portal to: access/upload new documents or request services for another child/individual. If you have any questions, please use our chat bot.

Required
Middle Name
Required
Required Invalid date of birth. Age must be more than 18 years. Date of birth can not be future date.
 

Required Invalid zip.
Required

Used only for internal communications & billing purpose

 
Step 3 of 6
3

Your Availability

What days and times would work best for you?

Click to select date & time. Click & drag to select multiple dates & times. Click day to select all times available.

Times
06:00 - 06:30 AM
06:30 - 07:00 AM
07:00 - 07:30 AM
07:30 - 08:00 AM
08:00 - 08:30 AM
08:30 - 09:00 AM
09:00 - 09:30 AM
09:30 - 10:00 AM
10:00 - 10:30 AM
10:30 - 11:00 AM
11:00 - 11:30 AM
11:30 - 12:00 PM
12:00 - 12:30 PM
12:30 - 01:00 PM
01:00 - 01:30 PM
01:30 - 02:00 PM
02:00 - 02:30 PM
02:30 - 03:00 PM
03:00 - 03:30 PM
03:30 - 04:00 PM
04:00 - 04:30 PM
04:30 - 05:00 PM
05:00 - 05:30 PM
05:30 - 06:00 PM
06:00 - 06:30 PM
06:30 - 07:00 PM
07:00 - 07:30 PM
07:30 - 08:00 PM
08:00 - 08:30 PM
08:30 - 09:00 PM
09:00 - 09:30 PM
09:30 - 10:00 PM
10:00 - 10:30 PM
10:30 - 11:00 PM
11:00 - 11:30 PM
11:30 - 12:00 AM

Tutorial:

Click once to select/unselect box.

Click and drag to select more box at once.

Click day to select all times available

Step 4 of 6
4

Payment Source

Please disclose all current active policies to determine benefits and eligibility and get services started sooner.

Please select a payment source
Do you have a type of Medicaid Insurance?
Yes
No
Medicaid Name
Required
Required
Medicaid Card Upload

Upload your Medicaid card images

+ Click To Upload

Required File name has special characters ~`!#$%^&*+=-[]\';,/{}|()":<>?. These are not allowed.

+ Click To Upload

Required File name has special characters ~`!#$%^&*+=-[]\';,/{}|()":<>?. These are not allowed.

If your card is on a single image please upload it in both places.

If you are unable to upload an image, please check this box and we will get in touch with you to help.
Do you have a type of Commercial Insurance?
Yes
No
Required
Required
 
Initial consent to services
Yes
No
Required

By clicking Yes(and providing your signature below) you are ensuring you are the legal guardian and have the authority to make decisions and provide consent for the client that is applying for services. In addition you are giving PBS Corp permission to:

  • Directly request comprehensive dignostic evalutions and referral documentation from health care providers and school personnel
  • Begin the assessment and behavior plan development process.
  • To use or disclose your protected health information(PHI) for treatment, payment and health care operations purpose.
  • By signing here, you consent to the utilization of your signature and the information provided in this application for the purpose of generating the documentation required for obtaining authorization with your insurance provider.
Please draw signature before Submit.

Parent Caregiver’s Signature

06/18/2024
Signature Date

Step 5 of 6
5

Diagnosis

Upload your diagnosis images

One or more diagnosis images

+ Click To Upload

File name has special characters ~`!#$%^&*+=-[]\';,/{}|()":<>?. These are not allowed.

Invalid date. Date of Diagnosis can not be future date.
 
Step 6 of 6
6

Language

Primary language spoken

Select language
English
Other
 

Captcha | verify to prevent spam

Complete captcha to proceed.
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