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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 (containing either the ADOS, CARS, or GARS tests); An active and signed IEP; A recent well child visit summary completed within the last year from PCP; and Letter of medical necessity recommending in-home ABA services from PCP
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