• Application for Services

    Application for Services

    Thank you for your interest in receiving ABA services from Kind Behavioral Health. We appreciate your inquiry and your trust in us as your provider. An intake coordinator will follow up shortly after you complete the form below to discuss next steps in our client intake process. If you have any questions on the form below, please do not hesitate to reach out to us at intake@carolinacenterforaba.com
    • An Intake Specialist will support you throughout the intake process and share ongoing updates on the status of your child’s application. 
    • We provide services to children between the ages of 1 and 21 years of age, with a confirmed diagnosis of autism spectrum disorder (F84.0) that specifies severity and level of support. 
    • We are in-network with all major insurance companies. We’ll conduct an insurance benefit check and give you a summary outlining any potential out-of-pocket expenses for services.  
    • You will be asked to complete and submit paperwork that will help us understand your child and their needs better. Be as detailed as possible so we can make the best team assignments. 
    • ABA is an intensive treatment. After a thorough assessment, your BCBA will recommend 15 to 35 hours of therapy per week for your child. We expect families to meet a minimum of at least 80% of the hours that were recommended, to ensure your child makes meaningful progress.  
    • The location of services (home, clinic, school, daycare, etc.) is determined by the BCBA at the time of assessment. The recommended location will align with your child’s learning goals and specific needs. 
    • We require that all children have a consistent therapy schedule, across 5 days, Monday-Friday, at a uniform time. Our time blocks include Morning (8:00-12:00), Midday (12:00-3:00) and Evening (3:00-7:00). 
    • Caregiver involvement in treatment is required as it has been shown to lead to better child outcomes. You will meet with your BCBA anywhere from 2 to 4 times per month to receive training that will empower you to implement your child’s Plan of Care.  
       
      Due to an increase in the number of applicants applying for ABA therapy in our service areas, please note that families are currently experiencing delays throughout the intake process. It is our primary goal to provide services for all families in a timely manner and we are working diligently to expand our resources to meet the current needs of our applicants. Our intake specialists are always available to assist you with any needs that may arise during this process and will provide regular updates regarding any anticipated delays. 
  • Client Information

    Please complete the following information.
  • Date of Birth*
     - -
  • Date*
     - -
  • Parent / Guardian Information

  • Format: (000) 000-0000.
  • Optional SMS Updates from KBH. You may choose to receive non‑marketing SMS text messages from Kind Behavioral Health (KBH), including intake confirmations, scheduling updates, appointment reminders, and support replies. Message frequency varies. Standard msg & data rates may apply. Reply STOP to unsubscribe or HELP for help. SMS participation is optional and not required to receive services. You may receive all communications by email or phone instead.*
  • Do you require translation services?*
  • Additional Information

  • Insurance Information:

  • Do you have insurance? If so, please select your active insurance provider(s)*
  • Insurance Information Georgia: 

  • Please Select your active insurance provider (s)
  • Diagnostic Information:

    A diagnosis of autism using a psychological evaluation and diagnostic test that includes the following information is required for services:

    • Diagnosis Code F84.0 (Autism Spectrum Disorder) and a date of diagnosis.
    • DSM Severity Level of Autism.
    • The diagnostic tool/test used to make the diagnosis (ADOS, CARS, etc.).
    • Medical provider signature with the credentials of MD, PhD, PsyD.

    *Testing administered by schools and other school documents (e.g., IEPs) typically do not meet the minimum requirements.

  • Format: (000) 000-0000.
  • Availability for Services:

    In order to best serve all clients’ needs, Kind Behavioral Health requires that client treatment schedules be set in accordance with our block scheduling guidelines.  Services shall be scheduled consistently week-over-week, and 5 days per week, Monday through Friday, at a uniform time of day.  Sessions should only extend across more than one of the standard blocks (described below) to the extent necessary to obtain the target level of treatment.

    Preliminary indications here are helpful in determining our ability to match your family's needs, and best plan our recruiting and onboarding efforts to reduce time spent on waitlists for all. Specific service schedules will be formalized following the completion of an initial assessment and creation of an individualized plan of care.

  • Select the time blocks you’re available for services Monday–Friday (5 days per week):*
  • Please indicate the preferred location of service, and check all that apply.
  • What is your preferred method of communication?
  • I understand that filling out any form associated with Kind Behavioral Health is not intended to create a doctor-patient relationship and that it is merely used to provide information to Kind Behavioral Health in order to determine whether I am a potential candidate for services. I also understand that in the future I may receive information from Kind Behavioral Health through electronic means, including without limitation e-mails and text messages, that may or may not be subject to the Health Information Portability and Accountability Act (“HIPAA”) rules and regulations, as well as state and local laws related to the privacy of personal information. I understand that there are risks associated in receiving information in this format, but still agree to receive future information in this format, regardless of whether I establish a relationship with Kind Behavioral Health.

  • Availability Meets Requirement
  • Should be Empty: