New Patient Intake

New Patient Intake Form
Part I: Patient and Family Information
Patient's Name *

First Name Last Name
Patient's DOB *

Month Day Year
Date
Patients's SSN *
Patient's Sex *
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 State

Zip Code
Caretaker/Guardian's Cell Number *

Area Code Phone Number
Caretaker/Guardian's Email *
example@example.com
Part II: Diagnosing Information.

** Regrettably, we will be unable to move forward with your application at this time unless you have a referral/prescription for Applied Behavior Analysis with a diagnosis of Autism Spectrum Disorder AND a full evaluation by a qualified specialist with a diagnosis of Autism Spectrum Disorder and recommendations for Applied Behavior Analysis **
Supporting Documents

Click here to upload
LIMIT 3 Files!: Refferal/Prescription for ABA AND Full Psych Evaluation with Diagnosis/Recommendation (Acceptable formats are pdf, doc, docx, zip, jpg, jpeg, png, gif) Cancel of
Part III:Primary Insurance Information
Carrier *
If you do not see your insurance carrier It means we are currently unable to complete the intake process at this time. Sorry for the inconvenience.
Relationship of Patient to Subscriber *
Name of Subscriber *

First Name Last Name
Subscriber ID *
Subscriber DOB *

Month Day Year
Date
Upload Primary Insurance Card (Front and Back) *

Browse Files
jpg, jpeg, png, gif Cancel of
Part IV: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 *
If you do not see your insurance carrier It means we are currently unable to complete the intake process at this time. Sorry for the inconvenience.
Relationship of Patient to Subscriber
Name of Subscriber

First Name Last Name
Subscriber ID
Subscriber DOB

Month Day Year
Date
Upload Secondary Insurance Card (Front and Back)

Browse Files
jpg, jpeg, png, gif ONLY Cancel of
Should be Empty:

New Patient Intake Form

Part I: Patient and Family Information

Part II: Diagnosing Information.

Part III:Primary Insurance Information

Part IV:Secondary Insurance Information