Skip to main content

Book A Consultation

Apply for Services.








    How did you hear about us?

    Preferred language during service
    Voorkeurtaal tydens sessie
    Idioma preferido durante el servicio
    allughat almufadalat 'athna' alkhidma

    English, Spanish, Arabic any other language


    Daycare Information (if applicable)







    Contact Information





    Days and Hours Desired for ABA Services



    Display some text when the checkbox is checked:

    [group Monday]

    [/group]

    [group Tuesday]

    [/group]

    [group Wednesday]

    [/group]

    [group Thursday]

    [/group]

    [group Friday]

    [/group]

    Insurance Information




    How did you hear about us?



    Policy Holder Date of Birth


    Relationship to Patient
    (e.g. Parent, Guardian, other)

    Does this child have NJ Family Care or Medicaid as a primary or secondary form of insurance

    Secondary Insurance
    Please use this field only if applicable.



    Insurance Card | FRONT
    Please upload an image of the FRONT of your Insurance Card.

    Insurance Card | BACK
    Please upload an image of the BACK of your Insurance Card.

    Autism DIAGNOSIS Report (IEP is not accepted by Insurance)
    Please upload a copy of your Autism DIAGNOSIS or IEP

    Emergency Contact Information




    Relationship to Patient
    Please describe the Emergency Contacts relationship to the Patient (e.g. Parent, Guardian, other)

    HIPAA Acknowledgement

    I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health insurance portability and Accountability Act of 1996 (HIPAA).

    I understand that by signing this consent I authorize Rainbow ABA to use and disclose my protected health information to carry out:

    • Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)

    • Obtaining payment from third-party payers (e.g. my insurance company)

    • The day-to-day healthcare operations of Rainbow ABA.

    I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA.

    I understand that you reserve the right to change the terms of this notice from time to time and that I may contact Rainbow ABA at any time to obtain the most current copy of this notice.

    I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

    I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

    Patient Name



    Signature

    Signature Date


    Relationship to Patient
    Please complete it if the Patient is unable to sign.

    Please be sure your insurance card is included or your insurance information is filled out before clicking SUBMIT below