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Massachusetts Autism Treatment Services Referral Form
About the Client
Date:
*
-
Month
-
Day
Year
Date
Client's Legal Name:
*
First Name
Last Name
Known As:
*
Gender Identity:
*
Female
Male
Transgender
Other
Date of Birth:
*
-
Month
-
Day
Year
Date
Language Needed for Services:
*
Would family be interested in a telehealth/hybrid model of ABA?
*
Yes
No
Would family be interested in Pride ABA services? (Specialty services for LGBTQ+ youth and families)
*
Yes
No
Insurance Information
Primary Insurance Type (If Commercial - please submit a photo copy of the insurance form):
*
MassHealth Standard - Beacon
MassHealth Standard - Tufts
MassHealth Standard - MBHP
MassHealth Standard - Wellsense
MassHealth Standard - Mass General Brigham
BCBS
Tufts (Commercial)
Beacon (Commercial)
Optum (Harvard Pilgrim)
Optum (United HealthCare)
Optum (UBH)
Other
Insurance ID:
*
If able please upload a picture of the front and back of your insurance card
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Policy Holder (if different than the client):
*
First Name
Last Name
Policy Holder Date of Birth:
*
-
Month
-
Day
Year
Date
Referral Contact Information
Legal Guardian:
*
First Name
Last Name
Legal Guardian's Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Legal Guardian's Email:
Legal Guardian's Relationship to Client:
Legal Guardian's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person Making Referral:
First Name
Last Name
Referent Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Referent Relationship to Client:
Referent Agency or Organization Affiliation:
Referral Source Title:
*
Referral Source Agency/Affiliation:
*
Other Information
Primary Contact:
*
First Name
Last Name
Primary Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Contact:
First Name
Last Name
Secondary Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Client:
*
Legal Guardian:
*
Yes
No
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Care Physician:
*
First Name
Last Name
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relevant Medical Information:
Diagnosing Contact (Psychiatrist, Psychologist, Neurologist or Developmental PCP):
*
First Name
Last Name
Does this client have an Autism Spectrum Disorder diagnosis?
Please Select
Yes
No
Unsure
Does this client have a Down Syndrome diagnosis?
Please Select
Yes
No
Unsure
School Information (Location, Grade, Special Education/Current IEP, Academic/Social Performance, Behaviors):
*
Other Information:
We will need the following documentation to consider the referral complete: An evaluation assigning or confirming ASD diagnosis (with testing), and an active and signed IEP or 504 plan. These documents can be submitted at a later date if necessary, but the child will not join the waitlist until the documents are submitted. The Intake Coordinator will review submitted documents and be in touch with what is still needed.
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