Form

Service Inquiry | Guardian & Patient Information

Your submission is an important first step in connecting with Unpuzzled Behavior Therapy.
After reviewing the information you've provided, the next step in our process will require gathering some additional documents to ensure we can offer the most appropriate and effective support for your child.

Guardian | Information

As the primary caregiver, your insight is invaluable to us.
Please provide some background information about yourself and your relationship with the patient.
This includes detailing how you're related to them and the best way for us to reach you for further communication.

Guardian | Relationship*

Guardian | Email*

Guardian | Phone Number*

Guardian | First Name*

Guardian | Last Name*

Guardian | Country/Region*

Guardian | Street address*

Guardian | City*

Guardian | State/Region*

Guardian | Postal code*

Patient | Information

Here is where you'll share crucial details about the child in need of our services.
Beyond the basic information, please let us know more about their situation:

Patient | Insurance Company*

Patient | Gender*

Patient | First Name*

Patient | Last Name*

Patient | Age*

Patient | Birthday*

Month/Day/Year

Patient | Diagnosis*

Patient | Did your child previously receive ABA services? If so where?*

Patient | Does your child attend school? If so, where?*

Patient | What services are you interested in?*

Patient | How would you describe your child’s verbal abilities? (please check one from the list below)*

Non-verbal (does not use words or signs to express any wants or needs)

Verbal (uses some words or signs to express wants or needs)

High-verbal (uses sentences to communicate and engages in conversation)

Patient | How would you describe your child’s problem behavior? (please check one from the list below)*

Compliant (does not engage in any concerning behaviors)

Mild (engages in minor problem behaviors like crying or whining occasionally)

Moderate (often has tantrums or persistent minor problem behaviors)

Severe (engages in a high frequency of concerning behavior, such as hitting, biting, and destruction)

Next Steps

Your submission is an important first step in connecting with Unpuzzled Behavior Therapy. After the information you've provided, the next step in our process will require gathering some additional documents to ensure we can offer the most appropriate and effective support for your child.

Here's what happens next:

1. Document Submission:
Please be ready to provide a Psychological Evaluation, a copy of the Insurance Card (front and back), and a Letter of Medical Necessity. These documents are crucial for the next phase of our process.

2. We'll Reach Out:
Expect a call or email from us within 2 business days regarding the submission of these documents and to discuss the next steps.

Your cooperation is greatly appreciated as we work together to support your child's needs. If you have questions or need assistance in the meantime, don't hesitate to get in touch.