Enrollment Forms
Welcome to ABA of Wisconsin! Our intake process involves a number of steps to ensure that your son/daughter’s needs are effectively assessed to design the most effective treatment for him/her. The information contained in this packet is intended to assist you in this process and provide our staff with the information necessary to expedite services. To fully enroll your son/daughter, you must fill out the forms listed below, provide the required documentation and return the material to us via email or fax. Upon receipt of this information, our Administrative Coordinator will make every attempt to schedule you with an available clinician. Please note, we currently have a wait list for after-school hours.
ENROLLMENT FORMS
☐ Client Information Form
☐ Authorization for Release of Information
☐ Insurance Verification Form & Copy of Insurance Card(s)
☐ Copy of Diagnostician Report or Most Recent Neuropsych Report
☐ Medicaid Physical Exam Form Completed and Signed by Primary Care Physician
☐ Medication List Completed and Signed by Primary Care Physician or Psychiatrist
☐ Copy of Current or Most Recent IFSP or IEP
☐ Availability Schedule
☐ Intake Interview Preparation Form
Please return completed forms and requested information via email or fax to:
Heather Hildeman, Administrative Coordinator
[email protected]
Phone: 331-481-6477
Fax: 630-395-9198
It is our mission to provide the highest quality, research-based behavioral services to assist your son/daughter in achieving his or her full potential. Our highly credentialed and experienced staff members use a person-centered approach and treat all individuals with respect and dignity. We take pride in our work and provide cutting edge and effective programs to assist clients in gaining the skills to learn, to work, and to live successfully with independence. Please feel free to contact us with any questions or concerns.
We look forward to working with you and your son/daughter!
ENROLLMENT FORMS
☐ Client Information Form
☐ Authorization for Release of Information
☐ Insurance Verification Form & Copy of Insurance Card(s)
☐ Copy of Diagnostician Report or Most Recent Neuropsych Report
☐ Medicaid Physical Exam Form Completed and Signed by Primary Care Physician
☐ Medication List Completed and Signed by Primary Care Physician or Psychiatrist
☐ Copy of Current or Most Recent IFSP or IEP
☐ Availability Schedule
☐ Intake Interview Preparation Form
Please return completed forms and requested information via email or fax to:
Heather Hildeman, Administrative Coordinator
[email protected]
Phone: 331-481-6477
Fax: 630-395-9198
It is our mission to provide the highest quality, research-based behavioral services to assist your son/daughter in achieving his or her full potential. Our highly credentialed and experienced staff members use a person-centered approach and treat all individuals with respect and dignity. We take pride in our work and provide cutting edge and effective programs to assist clients in gaining the skills to learn, to work, and to live successfully with independence. Please feel free to contact us with any questions or concerns.
We look forward to working with you and your son/daughter!
