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ABA Service Request Form

Once you have completed the following form, please submit accompanying documentation (diagnostic report, referral from a doctor for ABA services or a Medicaid Referral Form - if you have AL Medicaid) by email or fax to:

 

info@smithgroupbc.com           fax: 334-539-1971

ABA Service Request Form

Once you have submitted the following form, please download the accompanying intake paperwork, fill out, and return along with the following by email or fax:

 

  • Diagnostic paperwork from a medical doctor or psychologist showing diagnosis of Autism Spectrum Disorder within the past three years 

  • Referral for ABA services from a medical doctor or psychologist (or Alabama Medicaid Referral Form if you are insured by Medicaid)

  • A copy (front and back) of your insurance card

 

Email: info@smithgroupbc.com

Fax: 334-539-1971