Autism Request for Services Form

1
What service(s) are you requesting?* This field is required.
Genesis ABA
Genesis Diagnostic Assessment
General Information
2
Genesis only provides ABA services in our clinic. Will that work for your child?* This field is required.
YESNO
3
Is your child between 18 months and 8 years old?* This field is required.
YESNO
4
We believe a strong partnership with parents/guardians is critical to success. Are you willing to commit to participating in at least 3 parent support sessions a month and attending at least 3 months of family therapy?* This field is required.
YESNO
5
Does your child have a formal diagnosis of Autism?* This field is required.
YESNO
6
Genesis provides diagnostic services to assess if your child has Autism. See our website at the link below for more information.

Genesis Diagnostic Assessment Services
7
Do you plan to use Insurance?* This field is required.
YESNO
8
Was your child referred to Genesis for ABA services?* This field is required.
YESNO
9
Name of Referral Source
Name of Doctor, School, Etc.
10
Parent/Guardian Name* This field is required.
First Name
Last Name
11
Email* This field is required.
example@example.com
12
Phone Number* This field is required.
Please enter a valid phone number.
13
How did you hear about Genesis Autism Center?* This field is required.
Friend/Family Member
Doctor
Insurance
Web search (e.g., Google)
Genesis Counseling Center
Therapist
14
Does your child exhibit any of the following behaviors?* This field is required.
Hitting or scratching
Kicking
Biting
Property destruction
Self-Injurious behavior
None of the above
15
Child's Name* This field is required.
First Name
Last Name
16
Child's Date of Birth* This field is required.
17
Child's Sex* This field is required.
Male
Female
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
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Bahrain
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Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
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Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
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Democratic Republic of the Congo
Denmark
Djibouti
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Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
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Iran
Iraq
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Israel
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Jamaica
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Jersey
Jordan
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Kenya
Kiribati
North Korea
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Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
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Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
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Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
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Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
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United Kingdom
United States
Uruguay
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Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
19
Comprehensive Diagnostic ReportThe Comprehensive Diagnostic Report is an evaluation of the child’s cognitive and developmental functioning resulting in the child’s diagnosis, and is often performed by a psychologist, neurologist, psychiatrist, neuropsychologist, or medical doctor. You may have a copy of this report in your child’s records, or you may have to obtain a copy from the diagnosing professional. Depending on the child’s diagnosis, the report may involve information about the child’s history, parent or teacher interviews, behavioral observations, speech or language assessments, medical evaluations, genetic testing, or standardized cognitive assessments.
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Physician's Referral / ScriptThis document must include: a) Patient Name b) Patient Date of Birth c) “ABA therapy, evaluation and treatment” d) Specific ICD10 diagnosis code (e.g., F84.0 Autism Spectrum Disorder) Cannot be an "unspecified" code (e.g., F90.9 ADHD Unspecified is not accepted) e) Must be signed by an MD or DO. Signatures from an ARNP or PA-C are not accepted. f) Physician's name
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Physician's Contact Information
Physician's Name
Practice Name
Practice Phone Number
22
Is your Child Currently Attending:
Daycare
Pre-school
Kindergarten
Elementary School
Home School
23
Select Name of Insurance* This field is required.
Anthem
Anthem HealthKeepers Plus (Medicaid)
Aetna
Cigna
Molina/Magellan (Medicaid)
Sentara
Sentara Family Care (Medicaid)
TRICARE
Other
24
Policy Holder's Name* This field is required.
First Name
Last Name
25
Policy Holder's Date of Birth* This field is required.
26
Insurance Member ID Number* This field is required.
27
Insurance Group Number* This field is required.
28
Insurance Card Photo - FrontTake a photo of your insurance card with your phone camera or webcam to upload
29
Insurance Card Photo - Back
30
Insurance Card UploadIf you do not have a camera you can upload a copy of your insurance card - be sure to include both the front & back
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Max. file size: 10.6MB
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31
Do you have a Secondary Insurance Policy?* This field is required.
YESNO
32
Select Name of Secondary Insurance* This field is required.
Anthem
Anthem HealthKeepers Plus (Medicaid)
Aetna
Cigna
Molina/Magellan (Medicaid)
Sentara
Sentara Family Care (Medicaid)
TRICARE
Other
33
Secondary Insurance Policy Holder's Name* This field is required.
First Name
Last Name
34
Secondary Insurance Policy Holder's Date of Birth* This field is required.
35
Secondary Insurance Member ID Number* This field is required.
36
Secondary Insurance Group Number* This field is required.
37
Secondary Insurance Card Photo - FrontTake a photo of your insurance card with your phone camera or webcam to upload
38
Secondary Insurance Card Photo - Back
39
Secondary Insurance Card UploadIf you do not have a camera you can upload a copy of your insurance card - be sure to include both the front & back
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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40
Emergency Contact Information
Name
Phone number
Email
Address
41
Signature* This field is required.
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42
Date* This field is required.
Date
Month
Day
Year
43
Please let us know if you have any questions.
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Ok
44
Contact Form
Name
Please enter your phone
Please enter your email
How Can We Help?
45
By checking the box(es) below, you agree to receive email and/or SMS text messages (e.g., appointment reminders, communication from your child's therapist, requests for feedback, etc.) from Genesis Autism Center. You may text a reply of STOP at any time to opt-out of SMS text. Consent is not a condition of receiving services. Contact us on our website using secure webchat or call us at 757.664.9778 if you need assistance. Messages and data rates may apply for SMS text. Message frequency will vary. Learn more on our Privacy Policy and our Terms of Use webpages.
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