New Patient Intake Form
Part I: Patient and Family Information
Patient's Name
*
First Name
Last Name
Patient's DOB
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient's Sex
*
Male
Female
Caretaker/Guardian Filling out Form
*
First Name
Last Name
Relationship to Patient
*
E.g Mother,Uncle,Babysitter etc.
Caretaker Guardian Occupation
*
Patient's Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Caretaker/Guardian's Cell Number
*
-
Area Code
Phone Number
Have you had home ABA therapy in the past
*
Yes
No
Please share your experience
Are are willing to regularly participate in family training by the BCBA ?
*
Yes
No
Are you able to commit to at least 10 hours per week of direct ABA therapy?
*
Yes
No
Caretaker/Guardian's Email
*
example@example.com
Part II:Primary Insurance Information
**If you do not see your insurance carrier It mean we are not in network, and alternative arrangements will need to be made if services are to be rendered. If private pay, please select private pay and proceed to section IV**
Carrier
*
Aetna
Meritain Health
Compsych
Blue Cross Blue Shied (Commercial All States)
Wellpoint (Amerigroup Medicaid)
United Healthcare
Wellcare
Relationship of Patient to Subscriber
*
Self
Spouse
Child
Name of Subscriber
*
First Name
Last Name
Subscriber ID
*
Subscriber DOB
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Upload Primary Insurance Card (Front and Back)
*
Browse Files
jpg, jpeg, png, gif, pdf, doc, docx
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Part III: Secondary Insurance Information
Only use this section if your child has 2 entirely independent insurance policies. DO NOT just submit your primary policy information again. Select "none" if this does not apply to your child
Carrier
*
None
Aetna
Meritain Health
Compsych
GHI
Blue Cross Blue Shied (Commercial All States)
Horizon NJ Health (Medicaid)
Wellpoint (Amerigroup Medicaid)
United Healthcare
Wellcare
Relationship of Patient to Subscriber
Self
Spouse
Child
Name of Subscriber
First Name
Last Name
Subscriber ID
Subscriber DOB
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Upload Secondary Insurance Card (Front and Back)
Browse Files
jpg, jpeg, png, gif ONLY
Cancel
of
Part IV: Diagnosing and Supplementary Information.
** Diagnosis of Autism Spectrum Disorder is required for insurance based ABA therapy. For private pay, please upload any relevant information you believe will be helpful to your case in supporting documents **
Supporting Documents
*
Click here to upload
LIMIT 3 Files!: (Acceptable formats are pdf, doc, docx, zip, jpg, jpeg, png, gif)
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Please describe the services you are looking for
Private pay clients only
How did you hear about us?
*
Submit
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