Form

Does your child have an official autism (ASD) diagnosis?*

Yes

Unsure

Autism Evaluation Scheduled

An official autism spectrum disorder (ASD) diagnosis is required to obtain coverage through your insurance provider and to receive ABA services from our agency. An ASD diagnosis is only considered “official” when performed by one of the following:

Child Psychiatrist/Psychologist
Pediatric Neurologist
Developmental Pediatrician
Behavioral Pediatricians
PsyD (Dependent on State)
Psychologist (Dependent on State)

If you’ve received an ASD referral or recommendation from another medical professional or school-related provider, your insurance may not accept it. For questions about receiving an official ASD diagnosis, explore these resources from the National Institute of Mental Health at https://www.nimh.nih.gov/ . You may also look at Minder Memory Center who offer virtual diagnosis options. They are at https://www.mindermemory.com/

How does your child communicate? *

Gestures or not at all

One-word utterances

Single sentences

Regular speech

Child First Name*

Child Last Name*

Child Date of Birth*

Month/Day/Year

Child Gender*

Male

Female

Other

Parent/Guardian First Name*

Parent/Guardian Last Name*

Parent/Guardian Email*

Parent/Guardian Phone Number*

City

State/Region

What are the most significant obstacles for your child? (Select all that apply)*

What types of treatments are you looking for? (Select all that apply)*

How many hours per week are you able to commit to ABA therapy?*

15 Hours (minimum)

15-25 Hours

25-35 Hours

35-40+ Hours

Why investing time in ABA therapy is important:

All therapy hour recommendations are based on a detailed, in-depth assessment performed by a licensed BCBA. This ensures your child receives the exact amount of therapy needed to meet their individual needs and goals.

If you’re unable to meet the hours recommended by your BCBA and authorized by your insurance company, a few things can happen:

A lack of progress in your child’s development.
Difficulty having future ABA treatments approved by your insurance company.

To set your child up for success, we encourage all our families to utilize the full available hours authorized by your insurance company.

Primary Insurance Policy Name*

Primary Insurance Member ID*

Primary Card Holder Name*

Primary Cardholder Date of Birth*

Month/Day/Year

Do you have secondary insurance? *

Yes

Secondary Insurance Policy Name

Are you currently receiving ABA therapy from another agency/provider?*

Yes

Privacy Policy for SMS Communications

Effective Date: February 1, 2025

If you would like to receive text message communications, text START, YES, to this phone numbers: (307) 257-5487, (307) 212-3284 or (307) 213-6007 from Jackson Hole Behavioral Services LLC, DBA Peak Behavioral Services, LLC. You will be Opt-in to text messages.

Message frequency varies and may include SMS communication to improve engagement with clients, streamline operations, and enhance coordination. This includes updates on projects, scheduling confirmations, operational alerts, and other essential notifications. Message and data rates may apply. If you need assistance reply HELP for help. You may opt out at any time by replying STOP or CANCEL at any time to end or unsubscribe.

See our Privacy Policy below for details on how we handle your information.

https://pkservice.org/privacy-policy/

By submitting this form, I agree to receive text messages