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Client Intake Registration

Please fill out the following form to help us understand the service we can provide.

First Name of the Client Receiving Services

Last Name of the Client Receiving Service

Date of Birth of the Client needing service

Do you have an Autism Diagnosis? *

No

Yes

Gender of the Client Requiring Service *

Male

Female

Prefer not to disclose

Services Requested

Guardian/Caregiver First Name

Guardian/Caregiver Last Name

Address

City

State

Zip Code

Relationship to the Client *

Mother

Father

Legal Guardian

Other

Phone Number

Email

Insurance Information

Do you have Insurance? *

Yes

No (click submit to finish)

Self Pay ( click submit to finish)

Would you be able to upload your insurance card now? *

Yes

No

Upload File

Upload supported file (Max 15MB)

Upload File

Upload supported file (Max 15MB)

Insurance Company Name

Insurance Company Phone Number

Policy Member ID Number

Policy Holder Name

Policy Holder's Date of Birth

Group Name ID Number

Insurance Company Address

State

City

Zip Code

Country

Any additional you would like for us to know?

I declare that the info I’ve provided is accurate & complete

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Thanks for submitting!

Copyright © 2020 Applied Behavior Learning Center, LLC

Houston Applied Behavior Learning Center

Phone (713) 540-3032

Email: info@abxlc.com

1418 Live Oak St. Houston, TX, 77003

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