ABA Intake Request | Bright Futures ABA Therapy

Patient Intake

Intake Request Form

Patient Information

Patient Name(Required)

Patient DOB(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Select Your Center Location(Required)

View our locations here

Caregiver Information

Caregiver #1 Name(Required)

First Last

Caregiver #1 Phone(Required)

Caregiver #1 Email(Required)

Caregiver #2 Name

First Last

Caregiver #2 Phone

Caregiver #2 Email

Insurance Information

Insurance Carrier(Required)

Primary Cardholder Name(Required)

First Last

Primary Cardholder DOB(Required)

Primary Cardholder SSN(Required)

Primary Cardholder Group Number(Required)

Primary Cardholder Member ID(Required)

Secondary Cardholder Name(Required)

First Last

Secondary Cardholder DOB

Secondary Cardholder SSN

Secondary Cardholder Group Number

Secondary Cardholder Member ID

Referring Physician

Medical Records Release Information

Patient / Guardian Authorization: You may use or disclose the following health information...

Agree to Release All Health Information

I agree to release this information

All my health information including but not limited to AIDS/HIV and other Communicable disease information, Behavioral Health Care/ Psychiatric Care, Alcohol and/or drug abuse treatment, if any unless specifically excepted below.

Please list any information that are exceptions to this release.

Agree to Release Comprehensive Diagnostics

I agree to release this information

Comprehensive Diagnostic Evaluations or other Behavioral Health Diagnostic Tools

Consent to Release Additional Information

Other

Please list any additional information you agree to release.

You may disclose this health information to:
Name: Marcus Hibbard BCBA, LBA & Andrew Chism, MBA
Company: Therapy Dads, LLC d/b/a Bright Futures ABA
Address: 710 Clayworth Drive. Ballwin, Mo 63011
Phone: 314.390.6923 Fax: NA

How do you want to receive your child's medical records?

Fax

Mail

Patient Intake

Intake Request Form

Patient Information

Caregiver Information

Insurance Information

Medical Records Release Information

888-739-5556

contact@brightfuturesaba.org

2240 Bennington Place

Maryland Heights, MO 633048

500 Mariners Plaza Drive Suite B-2.

Mandeville, LA 70448

1500 Bauerle Rd

Hammond, LA 70403

10007 kennerly road

st. louis, missouri 63128

Patient Intake

Intake Request Form

Patient Information

Caregiver Information

Insurance Information

Medical Records Release Information

Hours of Operation

Maryland Heights

8:30AM - 4:30PM

Mandeville

8:00AM - 6:00PM

South County

8:30AM - 4:30PM

Hammond

8:00AM - 4:30PM