Paramount Behavior | Request ABA Therapy Services

Parent/Guardian Information

First Name *

Last Name *

Relationship to Child *

Phone Number *

Email Address *

Preferred Contact Method *

Home Address *

City *

State *

ZIP Code *

Child Information

Child's First Name *

Child's Last Name *

Date of Birth *

Gender *

School Name (if applicable)

Grade Level

Languages Spoken at Home

English Spanish Haitian Creole Portuguese Other

Medical & Diagnostic Information

Primary Diagnosis *

Date of Diagnosis

Diagnosing Provider

Other Medical Conditions or Concerns

Current Medications

Previous Therapies/Services

ABA Therapy Speech Therapy Occupational Therapy Physical Therapy None

Service Needs & Goals

Services Requested *

In-Home ABA Therapy School Support Services Parent Training Behavioral Assessment Consultation Only

Primary Areas of Concern *

Communication/Language Challenging Behaviors Social Skills Daily Living Skills Academic Skills Safety Awareness

Specific Goals or Concerns *

Preferred Start Date

Preferred Service Hours

Insurance & Payment Information

Payment Method *

Additional Information

Documents & Consent

Upload Documents (Optional)

Diagnosis Report (PDF/JPG, max 5MB)

Choose File

IEP/504 Plan (if applicable)

Choose File

Insurance Card (Front & Back)

Choose File

Consent & Authorization

I consent to being contacted by Paramount Behavior regarding this service request I consent to an initial evaluation to determine service needs I certify that all information provided is accurate to the best of my knowledge I have read and agree to the Privacy Policy

Electronic Signature * By typing your name, you are electronically signing this form

What happens next?

After submitting this form, our intake coordinator will contact you within 1-2 business days to discuss your child's needs and schedule an initial consultation.