New Patient Intake Form
Part I: Patient and Family Information
Patient's Name
*
First Name
Last Name
Patient's DOB
*
/
Month
/
Day
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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)
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Part III:Primary Insurance Information
Carrier
*
Aetna
Cigna
United Healthcare
Oxford
Blue Cross Blue Shied
Humana Military (Tricare)
Amerigroup
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
*
Self
Spouse
Child
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, pdf, doc, docx
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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
*
None
Aetna
Cigna
United Healthcare
Oxford
Blue Cross Blue Shied
Humana Military (Tricare)
Amerigroup
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
Self
Spouse
Child
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
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How did you hear about us?
*
Submit
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