Thanks for choosing Indiana ABA Institute!

IABAI accepts most forms of insurance, including Medicaid. Our professional medical billing partners can assist with the verification of coverage and the filing of claims. IABAI also accepts private payment for services.

If you are interested in receiving services, please fill out the form below as completely as possible.



    Intake Application


    * Indicates required fields. It is not recommended to use Safari to fill out this form.

    Child's Information

    Child's Name*

    Child's Date of Birth*

    Child's Social Security #*

    Child's Gender*

    Caregiver Information

    Caregiver Name*

    Relationship to Child*

    Email*

    Primary Phone #*

    Secondary Phone # (optional)

    Address*

    City*

    State*

    Zip Code*

    Diagnosis

    Autism Diagnosis*
    YesNo

    Secondary Diagnosis (if applicable)

    Physician Name*

    Physician Contact #*

    Specialist Name (if applicable)

    Specialist Contact # (if applicable)

    Diagnostic Report* (optional, one file only, PDF recommended)

    Psychological Evaluation (optional, one file only, PDF recommended)

    If you need assistance with scanning documents and creating PDF files with your device click here for iphone or here for Android device. If you are unable to upload a document, you can Email the attachment.

    Primary Insurance

    Primary Insurance Provider*

    Primary Insurance Member ID#*

    Primary Insurance* (one file only, PDF recommended, include front and back of card)

    If you need assistance with scanning documents and creating PDF files with your device click here for iphone or here for Android device.If you are unable to upload a document, you can Email the attachment.

    Secondary Insurance

    Secondary Insurance Provider (optional)

    Secondary Insurance Member ID# (optional)

    Secondary Insurance (optional, one file only, PDF recommended)

    If you need assistance with scanning documents and creating PDF files with your device click here for iphone or here for Android device. If you are unable to upload a document, you can Email the attachment.

    Child's Behaviors (choose one per category)

    Aggression* (choose one)
    DailyWeeklyMonthlyRarely/Never

    Refusals* (choose one)
    DailyWeeklyMonthlyRarely/Never

    Self-Injurious Behavior* (choose one)
    DailyWeeklyMonthlyRarely/Never

    Elopement* (choose one)
    DailyWeeklyMonthlyRarely/Never

    Property Destruction* (choose one)
    DailyWeeklyMonthlyRarely/Never

    Disrobing* (choose one)
    DailyWeeklyMonthlyRarely/Never

    Tantrum* (choose one)
    DailyWeeklyMonthlyRarely/Never

    Additional Behavioral Information

    Child's Verbal Behavior*
    VerbalNon-Verbal

    Child's Strengths* (minimum length is 100 characters)

    Further Details* (minimum length is 100 characters)

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