Contact

ABA Direct, LLC

Contact ABA Direct to learn more about our ABA services across our growing service areas.To get started, please complete our Intake Screening Form below. This secure form helps us understand your child’s needs, verify insurance, and determine service availability so we can guide you through the next steps efficiently. We look forward to connecting with you and supporting your family.

    CONTACT & CLIENT BASICS

    Caller Name*

    Relationship to Client*

    Phone Number*

    Email Address*

    Client Full Name*

    Date of Birth*

    Client Age

    City*

    State*

    Is Client in School?*

    YesNo

    Is Client in ABA?*

    YesNo

    Preferred Service Setting(s)*

    In-Home ABACenter-Based ABADaycare-Based ABA

    Insurance Type*

    GUARDIAN AND INSURANCE INFORMATION

    Guardian 1 Details

    Guardian Name*

    Guardian Relationship*

    Guardian Address*

    Guardian Phone*

    Guardian Email*

    Add a Second Guardian?

    NoYes

    Guardian 2 Details

    Guardian Name*

    Guardian Relationship*

    Guardian Address*

    Guardian Phone*

    Guardian Email*

    INSURANCE INFORMATION

    Is Medicaid Primary?*

    YesNo

    Primary Insurance Name*

    Is Tricare Primary?*

    YesNo

    Primary Insurance Name*

    Is Aetna Primary?*

    YesNo

    Primary Insurance Name*

    Is Amerigroup Primary?*

    YesNo

    Primary Insurance Name*

    Is PeachCare Primary?*

    YesNo

    Primary Insurance Name*

    Is CareSource Primary?*

    YesNo

    Primary Insurance Name*

    Is BlueCross / BlueShield Primary?*

    YesNo

    Primary Insurance Name*

    Is Optum / UMR / UHC Primary?*

    YesNo

    Primary Insurance Name*

    Home & Family Overview

    Family Members in Home*

    Legal/Social Stressors

    Cultural Considerations

    School and Service Settings

    School Name*

    Grade Level*

    Classroom Placement

    Active IEP?*

    YesNo

    Daycare Name*

    Daycare Contact Person*

    Daycare Phone*

    MEDICAL & ABA HISTORY

    Diagnosis*

    Medical Conditions

    Allergies?*

    YesNo

    Allergy Description*

    Epi Pen Required?*

    YesNo

    Current Medications


    Add more

    Prescribing Physician*

    Diagnosis of Autism?*

    YesNo

    Would you like info about evaluation?*

    YesNo

    Preferred Evaluation Partner

    Evaluation Partner Contact Information

    Current ABA?*

    YesNo

    Current ABA Details*

    Previous ABA?*

    YesNo

    Previous ABA Outcomes*

    Diagnosis Report?*

    YesNo

    Current Referral / Letter of Medical Necessity?*

    YesNo

    AREAS OF CONCERN & AVAILABILITY

    Areas of Concern*

    AllergiesVisionHearingFeedingSleepSensoryGI IssuesOther

    Other Concern Description*

    Behaviors*

    ElopementAggressionNoncomplianceTantrum BehaviorsSelf InjuryProperty DestructionMouthingPICAOther

    Parent Training Participation*

    YesNo

    Guardian Availability

    Guardian 1 Availability*

    Mon 8-12Mon 12-3Mon 3-6Mon After6Tue 8-12Tue 12-3Tue 3-6Tue After6Wed 8-12Wed 12-3Wed 3-6Wed After6Thu 8-12Thu 12-3Thu 3-6Thu After6Fri 8-12Fri 12-3Fri 3-6Fri After6Sat 8-12Sat 12-3Sat 3-6Sat After6

    Guardian 2 Availability*

    Mon 8-12Mon 12-3Mon 3-6Mon After6Tue 8-12Tue 12-3Tue 3-6Tue After6Wed 8-12Wed 12-3Wed 3-6Wed After6Thu 8-12Thu 12-3Thu 3-6Thu After6Fri 8-12Fri 12-3Fri 3-6Fri After6Sat 8-12Sat 12-3Sat 3-6Sat After6

    Treatment Availability*

    Mon 8-12Mon 12-3Mon 3-6Mon After6Tue 8-12Tue 12-3Tue 3-6Tue After6Wed 8-12Wed 12-3Wed 3-6Wed After6Thu 8-12Thu 12-3Thu 3-6Thu After6Fri 8-12Fri 12-3Fri 3-6Fri After6Sat 8-12Sat 12-3Sat 3-6Sat After6

    Who Referred You?*

    Still have questions? Contact us below.

      Patrick Thorbourne, M.Ed, BCBA

      Google
      Facebook

      Flagship
      201 Joseph E. Lowery NW
      Atlanta, GA, 30314
      phone number- 470 887 7673
      In-home communities served: 
      Conyers, McDonough, Hampton, Riverdale, South Fulton, Mableton

      Email

      patrick@hi5aba.com

      Phone

      (770) 865-7722

      Fax

      14048066662

      ABA Direct – Atlanta, GA