Start ABA Services | Blooming Behavioral Health

🧒 Child Information

Tell us a little about the child so we can begin the intake process.

Child's Full Name *

Date of Birth *

Gender

Street Address *

City *

State *

ZIP Code *

👤 Parent or Guardian Information

We'll use this information to contact you about eligibility, next steps, and scheduling.

Parent / Guardian Full Name *

Relationship to Child *

Phone Number *

Email Address *

🩺 Clinical and Developmental Concerns

Select any concerns that apply. This helps our team understand your child's needs before follow-up.

What concerns do you have about your child's development or behavior? *

Current diagnosis, if any (optional)

📋 Insurance Information

This helps us determine eligibility and next steps for services.

Insurance Plan Name

Member ID Number

Policy Holder Name

Secondary Insurance?

Yes No

🏠 Service Preferences

Let us know where and when services may work best for your family.

Preferred Service Location

HomeSchoolCommunityUnsure

Has your child received ABA before?

Yes No

Current provider involved?

Yes No

How did you hear about us?

📎 Upload Documents

You may upload any documents that would help us review your registration more quickly.

Upload insurance card, diagnosis report, referral, or other supporting documents

Accepted files: PDF, JPG, PNG, DOC, DOCX

📝 Additional Notes

Share anything else that may help our team support your family.

Is there anything else you would like us to know?

✅ Consent

Please review and confirm before submitting.

I confirm that the information provided is accurate to the best of my knowledge. I consent to be contacted by Blooming Behavioral Health regarding ABA services, intake, and scheduling.