Client Online Enrollment Please complete the Riley ABA & Autism Center Enrollment form. Fields marked with * are required. Enrollment First Name*Client First NameLast Name*Client Last NameBirthdate* Date Format: MM slash DD slash YYYY Gender*MaleFemaleHow Did You Hear About Us?*Search/GoogleSocial MediaDoctorProfessional in the CommunityFamily Friend or Riley ABA EmployeeWalk-InEventNewspaper/Magazine/RadioInsurance ProviderDiagnosing Physician*Referring PhysicianCurrent ABA Service ProviderPrimary InsurancePrimary Insurance*Please list insurance provider. If you do not have insurance, please put "none".Primary Policy Holder's DOB* Date Format: MM slash DD slash YYYY If you are planning to bill insurance, please provide the policy holder's DOB. This is required.Tricare Member ID#If you are a Tricare beneficiary, please list your Member ID #. This is required.Insurance Holder’s EmployerSecondary InsuranceSecondary Insurance & Policy Holder's DOB Date Format: MM slash DD slash YYYY Please list secondary insurance provider and policy holder's DOB.Contact InformationParent/Guardian First Name*Parent/Guardian Last Name*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Home PhoneWork PhoneEmail* Your login information will be sent to this addressPreferred Method of Communication*Phone CallEmailEmail permissions*By submitting this application, I give Riley ABA permission to email me information about ABA TherapyUncertain at this timeFilesDiagnostic Report*Please upload the full diagnosis report from a licensed medical professional (note: school evaluations are not recognized as a formal diagnosis for insurance purposes). Photo images of the report are not acceptable when submitted to insurance. Please upload the all pages of the report as a PDF. This is a required document.ABA PrescriptionPlease upload your prescription for ABA therapy on a script pad stating your child needs ABA therapy. If you have Tricare you will not need a prescription. If the diagnosis report recommends ABA therapy, you will not need a separate prescription.Primary Insurance (Photo of FRONT)Please use this option to upload a photo of the FRONT of your insurance card.Primary Insurance Card (Photo of BACK)Please use this option to upload a photo of the BACK of your insurance card.Secondary Insurance (Photo of FRONT)Please use this option to upload a photo of the FRONT of your secondary insurance card.Secondary Insurance (Photo of BACK)Please use this option to upload a photo of the BACK of your secondary insurance card. This iframe contains the logic required to handle Ajax powered Gravity Forms.