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

 
 

+ Add Parent/Caregiver

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.

Check All
Clear
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
 
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
 

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