ENROLLMENT

Our team at rising stars aba is committed to educating and assisting families navigate their way.

Through diagnosis and treatment of their loved ones. We are ready to serve you at every step of the process and answer every financial and treatment process. We promise support and transparency through this process.

Step 1: Complete intake/enrollment forms.

Step 2: Wait for the intake coordinator to contact you for any additional forms needed, and to discuss the next step(s).

APPOINTMENT REQUEST

Submit your insurance card for benefits information TODAY!

Contact Information

PARENT/GUARDIAN FIRST NAME *

PARENT/GUARDIAN LAST NAME *

PRIMARY EMAIL *

CELL PHONE *

ADDRESS - LINE 1 *

ADDRESS - LINE 2

CITY *

STATE *

ZIP/POSTAL CODE *

Child Information

FIRST NAME *

LAST NAME *

BIRTH DATE *

GENDER

CURRENT INSURANCE *

INSURANCE BENEFITS AND ELIGIBILITY RELEASE OF INFORMATION *YesNo

"Yes" I allow Rising Stars ABA to contact my insurance provider for a B&E check

DAYS AVAILABLE TO WORK *MonTueWedThuFriSatSun

DOES YOUR CHILD HAVE A MEDICAL DIAGNOSIS OF AUTISM? YesNo

IF YES, PLEASE PROVIDE DIAGNOSIS

Optional Information

INSURANCE SUBSCRIBER'S NAME

INSURANCE SUBSCRIBER'S DATE OF BIRTH

HOW DOES YOUR CHILD COMMUNICATE?Spoken WordsSign LanguageUse of a Communication DeviceUse of a Communication Device

DOES YOUR CHILD ENGAGE IN ANY BEHAVIORS OF CONCERN?YesNo

DO YOU HAVE ANY CONCERNS REGARDING FEEDING?YesNo

HOW DID YOU HEAR ABOUT US?

Files

DIAGNOSTIC (DX) EVALUATION (accepted file formats: .doc, .docx, .pdf | max: 10mb)

INSURANCE CARD (FRONT) (accepted file formats: .doc, .docx, .pdf | max: 10mb)

INSURANCE CARD (BACK) (accepted file formats: .doc, .docx, .pdf | max: 10mb)

Rising Stars ABA is a modern, comprehensive, and accessible ABA therapy clinic that provides world-class treatment for children and teens on the autism spectrum.

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Our Therapy

Center -Based ABA Therapy
School-Based ABA Therapy
In-Home ABA Therapy
After-School ABA Therapy

Contact Info

832-617-5859
info@risingstarsaba.com
6909 Brisbane Ct, STE 250, Sugarland, TX, 77479

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