Form – ABA Therapy – Mindsource Center

Thank you for your interest in MindSource Center’s Applied Behavior Analysis (ABA) services. We look forward to serving your family.

Our services are provided primarily at the MindSource Center clinic, conveniently located in Kent/Covington, across from the Covington Library, at: 27023 164th Ave SE, Covington, WA 98042. If you live in one of the following South King County communities, you may be eligible to receive in-home ABA services: Auburn, Black Diamond, Covington, Federal Way, Kent, Maple Valley, and Renton.

Applied Behavior Analysis services at MindSource Center may be partially or fully covered by your health insurance plan. For your convenience, we are contracted as preferred providers with most major insurance plans, including Regence, Premera, Optum/United Behavioral Health, First Choice, Lifewise, and others. We do not accept Medicaid, Cigna or TriCare as primary insurance plans.

Please complete the following information so that we know best how to assist you. You can expect a response from our team shortly.

ABA Services Request

ABA Inquiry Form

PARENT / GUARDIAN INFORMATION

First Name:(Required)

Last Name:(Required)

YOUR ADDRESS

Street:(Required)

City:(Required)

Zip:(Required)

Phone Number:(Required)

Email Address:(Required)

Preferred Method of Contact:

Phone

If phone, best time to contact:

CLIENT INFORMATION (Who will be receiving services?)

First Name:(Required)

Last Name:

Date of Birth:(Required)

Does this individual have an autism spectrum diagnosis?(Required)

Primary language spoken in-home:

English

Other

If "other", what is the primary language spoken in home

Secondary language spoken in home:

Describe your main areas of concern:

Does your child engage in severe maladaptive behaviours?

If yes, describe the behaviours:

Does your child attend school?

If Yes, will our child be available to receive ABA services between during school hours?

Hours for availability (check all that apply):

8 am - 3:30 pm

8 am - 12 pm

12 pm - 3:30 pm

3:30 pm - 6 pm

Are you able to receive ABA services at the MindSource Center clinic?

Name of health insurance plan:(Required)

Whom may we thank for referring you?

Inquiry Form

ABA & Social Programs

ABA Services Request

ABA Inquiry Form

Trusted Autism Experts

Serving South King County Families since 2003