Welcome to AblePath!

Your First Step Toward Getting Your Child the Support They Deserve

Thank you for choosing AblePath. By completing this short application, you're taking the first real step toward getting your child the personalized, compassionate ABA therapy they need.

This takes about 5 minutes. Once submitted, our team will begin reviewing your information and reach out within 1-2 business days with next steps.

Need help? We're here. Call or text us at (980) 410-5300 or email [email protected]

With warmth, The AblePath Team

Child's Information

Child's First Name

Child's Last Name

Preferred Name (if different)

Date Of Birth

Home Address

City

State

ZIP Code

Child's Gender

Child's Primary Language

English

Spanish

Other

If Other, please specify language

Contact Information

Primary Guardian

Guardian 1 Full Name

Relationship to Child

Guardian Primary Phone Number *

Secondary Phone Number

Guardian Email Address *

Preferred Method of Contact

Phone Call

Text

Email

Best Times to Contact

Morning

Afternoon

Evening

Guardian 2 Full Name

Guardian Relationship to Child

Primary Phone Number

Email Address

Emergency Contact Information

Emergency Contact Name

Relationship to Child

Emergency Contact Phone Number

If Other, please specify

Insurance Information

Primary Insurance Card - Front

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Primary Insurance Card - Back

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Secondary Insurance Card - Front

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Secondary Insurance Card - Back

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Diagnosis Information

Upload Diagnostic Report

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Some doctors include a recommendation for ABA therapy right inside the diagnostic report - usually a line that says something like 'ABA therapy is recommended' or 'the child would benefit from behavioral intervention.' If yours says something like that, you're all set.

If your report doesn't mention ABA therapy at all, your doctor will need to send us a separate referral. Not sure? Upload your report below and our team will check for you.

Is a referral included in the diagnostic report

Yes

No

If No, please upload referral separately

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Goals and Preferences

What are your primary goals for ABA therapy? What would you most like to see change or improve for your child

Preferred Therapist Gender

Preferred Therapist Language

If Other, please specify language

Preferred Therapist Cultural Background

Weekday Preferred Times (Please note, times do not have to be exact. We are just getting an idea of when you are looking for services)

Morning (8am-12pm)

Afternoon (12pm-4pm)

Evening (4pm-7pm)

Full Day (9am-5pm)

Weekday Preferred Times

Morning (8am-12pm)

Afternoon (12pm-4pm)

Evening (4pm-7pm)

Full Day (9am-5pm)

Preferred Location for Services

Informed Consent and Service Agreement

Signature of Guardian

Printed Name

Date

Next