Before we begin

Please use this form for intake requests only. Do not include medical records, insurance card images, or emergency information.

You can review our clinic policies and disclaimer before submitting.

I understand Brown Bear ABA Clinic will contact me about services and insurance next steps.

Parent or caregiver information

Parent or caregiver name Relationship to child Phone Email Home address City State

Child first name Child last name Date of birth Diagnosis, if known When was the last diagnosis done? Main concerns or goals

Insurance plan Member ID Policyholder name Policyholder date of birth Insurance notes

Speech therapy and occupational therapy are offered together with ABA enrollment at this time, not as standalone services.

ABA service setting ABA in clinic ABA in home ABA in clinic and home Not sure yet

Additional services with ABA Speech therapy with ABA Occupational therapy with ABA Insurance verification support

Anything else we should know?

Best days Monday Tuesday Wednesday Thursday Friday Saturday

Available start time Available end time Preferred contact method Schedule notes