Fill the ABA Referral Form Online

1 · Patient

Patient full name *

Date of birth

Age

Sex

Home address

City

ZIP

School / daycare (if any)

Grade

IEP / 504?

Child's primary language

2 · Parent / legal guardian

Guardian name

Relationship

Phone

Email

Second contact (name)

Relationship

Phone

Best time to call

Our team works in English and Spanish. For any other language we arrange a qualified interpreter at no cost to the family.

Family knows about this referral

Yes — they expect our callNot yet — please introduce us

3 · Insurance

Primary plan

Member ID

Group #

Policy holder + DOB

Secondary plan (if any)

Member ID

Medicaid ID (if separate)

4 · Diagnosis & clinical picture

Diagnosis / ICD-10 (all that apply)

Date of diagnosis

Diagnosing provider

Diagnosis status

Confirmed — evaluation availableSuspected — evaluation needed

Current medications (name / dose)

Other therapies now (speech, OT, PT — hrs/wk)

Previous ABA? (agency / when)

Reason for referral & current concerns *

Behaviors, skills, communication, recent changes — anything that helps us triage.

5 · Referring provider / school

Name & credentials *

NPI *

Phone *

Practice / school

Fax or email for our report back *

Referral source

PCP / pediatricianSpecialistSchoolFamily self-referral

6 · Safety & urgency

Check anything present. This is what moves a referral up the list.

Urgency

RoutineExpedited — placement at riskUrgent — safety

7 · Services requested

Days / times the family is generally available

Anything we should know before we call

8 · Documents

Other — what

Upload those documents here

PDF, JPG or PNG · up to 5 files, 4 MB each. Send what you have — our intake team chases the rest with the family.

Sign and send

Choose how you want to sign — any one of the three is enough.

How do you want to sign? Draw it here — mouse, trackpad or finger. Draw it on my phone — we give you a link and a QR code. Type my name instead — for signing with a keyboard only, or when drawing is not possible on any device.

✍️ Draw it here — mouse, trackpad or finger

Type your full name to sign *

NPI (if applicable)

Add my location to the signature record (optional). Your browser will ask permission first.

Signing records your name, the date and time with your time zone, this page, your browser and — only if you tick the box — your coordinates. Under the E-SIGN Act this signature has the same legal effect as one on paper.

I agree to receive conversational and informational SMS messages from American Institute of Mental Health regarding appointments, scheduling, intake, insurance verification, billing notifications, customer support, and other service-related communications. Message frequency varies. Message and data rates may apply. Reply STOP to opt out. Reply HELP for more information. Consent is not a condition of receiving services. View our Privacy Policy and SMS Terms & Conditions.

Optional — you can send the form without agreeing to text messages.

How would you like to send it?

Send it from this page. Fastest. We receive it right away, you get a confirmation number, and intake calls the family within 24–48 hours. A signed copy downloads for your records and another goes to your email. Just build the PDF — I'll send it myself. The form downloads to your computer with everything filled in and the reference number on every page, and we open your own email program ready for you to attach it. Signing here is optional with this option: leave the signature blank and the PDF stays editable so you can print it and sign it by hand. Nothing about the patient is stored on our servers with this option — the form never leaves your hands until you send it.