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Starting the Intake Process

If you are ready to proceed with the new client intake process, please complete our new client basic information form below. For details regarding coverage for ABA, Speech, and Occupational Therapy services through health insurance, please call (781)) 290-3886 or email us and one of our administrative staff will be happy to assist you.

After the initial contact is made, our staff will determine your eligibility and benefits for ABA, Speech, and Occupational Therapy services by contacting your health insurance carrier. Verification of eligibility and benefits for ABA, Speech, and Occupational Therapy services does not commit potential clients to services through Proven Behavior Solutions. We verify eligibility and benefits as a courtesy to all potential clients.

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Please Complete the Form Below to Get Started

"*" indicates required fields

Caregiver Information*
Preferred contact method
Interested In
Check if applicable:
Insurance Information - if seeking ABA, OT, Speech & AAC
Primary:
Secondary:
 
Client Information*
MM slash DD slash YYYY
Gender of child
If autism, what is the approximate date of initial diagnosis and/or most recent re-evaluation?

General Availability

MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY

Primary Insurance Eligibility Information

Policy Holder Name
*If MassHealth, the client is the Policy Holder
MM slash DD slash YYYY

(if applicable)

Secondary Insurance Eligibility Information

(if applicable)
Policy Holder Name
*If MassHealth, the client is the Policy Holder
MM slash DD slash YYYY

(if different from above)
(if different from above)
(if applicable)

Please provide a picture of the front and back of your insurance card(s)

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