Client Information
Austism Evaluation: ADOS Referral
Date
*
-
Month
-
Day
Year
Date
Client's name (child)
*
First Name
Last Name
Client's Date of Birth
*
-
Month
-
Day
Year
Date
Client's Age:
*
Client's Gender:
*
Client's SSN
*
SSN
*
Who is the child living with?
*
First Name
Last Name
What is the Relationship between the child and adult living with them?
*
Relationship
Where is the child located?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of adult living with child: (no case manager info)
*
Format: (000) 000-0000.
Email of adult living with child: (no case manager info)
*
example@example.com
Is the Client in School?
*
Yes
No
Grade:
*
What is the name of the School?
*
Write N/A if not applicable.
Are they in an early steps?
*
Write N/A if not applicable
Which Insurance does Client have?
*
Please Select
None
Aetna Commercial
Aetna Medicaid
Ambetter
Simply Healthcare
Humana Medicaid
Vivida Health Medicaid
Clear Alliance Medicaid
BCBS/Florida Blue
CIGNA
Maestro Health
Oscar
UHC Commercial
UHC Medicaid
Sunshine
CMS
Wellcare
Other
This drop down contains all the Insurances we are in-network with, but that is not a guarantee of coverage for the services provided.
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Referral Information
Referral Source
*
ABA Professional
APRN
Neurologist
Pediatrician
Psychiatrist
Psychologist
APD
Other
Referral Source Phone Number:
*
Format: (000) 000-0000.
Referral Source Email:
*
Case Manager Name (If Applicable)
First Name
Last Name
Case Supervisor Name (If Applicable)
First Name
Last Name
Address of Place of Referral:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Clinical Concerns
Delay in Social Communication and Interaction Skills
Restricted or Repetitive Behaviors or Interests
Delayed language skills
Delayed movement skills
Delayed cognitive or learning skills
Hyperactive, impulsive, and/or inattentive behavior
Epilepsy or seizure disorder
Unusual eating and sleeping habits
Unusual mood or emotional reactions
Anxiety, stress, or excessive worry
Lack of fear or more fear than expected
Other necessary details we need to know about this referral:
*
Other necessary details we need to know about this referral:
*
PLEASE NOTE:
Once we receive the approval our office will contact the client directly. Please do not ask the client to contact the office independently as this sometimes will cause confusion and delays.
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Parent's Concerns
Please describe all significant functional impairments that apply. If it does not apply, write N/A. Do not write an email address or any other personal information.
At Home:
At School:
If applicable.
Legal:
Have any safety precautions been taken by the law due to Client's behavior?
At Home:
*
At School:
*
If applicable.
Legal:
*
Have any safety precautions been taken by the law due to Client's behavior?
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Patient History
If no services have been received, mark Other and write "None"
History of Services Received such as:
*
Occupational Therapy
Speech Therapy
Physical Therapy
School Accommodations (IEP/504)
Counseling
Applied Behavioral Analysis (ABA)
Other
Our Information
2700 W MLK JR BLVD, SUITE 250 , TAMPA FL 33607 | PHONE: 888-666-3089 | FAX: 888-666-9870
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