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Our professionalism is a testament to the excellence in service we strive to maintain.

Complimentary Screening

Our team offers complimentary screenings which may include the following: brief preliminary intake assessment with initial goals and objectives, a review of funding source(s), verification of benefits, a question and answer session, and/or a review of services offered. Currently we do have a wait period for services but, please fill out the form to initiate a review, thank you! Call 502-409-7181 for any questions at all, we’ll be happy to speak with you today.

Step 1

Click on the link to complete the Preliminary Intake Assessment (PIA).

Step 2

Fill out all applicable fields (on right).

Step  3

Attach any supporting documents.

Step 4


Step 5

A CBA Care Team representative will be contacting you within 1-2 business days with further instructions.



  • Basic Information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Check all that apply.
  • Check all that apply.
  • Basic Information is Complete

    If you have insurance continue to next section. If you are finished, press SUBMIT (at bottom of page).
  • Primary Insurance Information

  • Secondary Insurance (if applicable)

  • Subscriber Information

  • Date Format: MM slash DD slash YYYY
  • Verification of Benefits

    To help you understand and verify your insurance coverage, please call your insurance plan and verify your benefits for ABA coverage. The number to call should be on the back of your insurance card.
  • What is the patient financial responsibility?

  • Upload copy of front and back of card
    Drop files here or
    • For participants with commercial health insurance or Medicaid managed care plans (MCOs) a diagnostic evaluation report is required for services to be considered. Please upload here.
      Drop files here or
      • Consent and Release

        I hereby consent to treatment by, and authorize insurance benefits to be paid directly to Clinical Behavior Analysis. I agree that I am responsible to pay, (1) for services not covered by my insurance company, (2) co-payments and deductibles, (3) any expense associated with the collection of a debt owed to them by me (i.e. attorney fee, court cost or collection agency fee) and (4) I agree that I have not other form of Insurance that covers ABA therapy services. I also consent to the release of pertinent medical information to my insurance carrier(s) for the purpose of verifying benefits and processing healthcare claims.
      • This field is for validation purposes and should be left unchanged.