Autism Counseling & Support Services

Client's telephone number:*
Please enter a valid phone number.
Client's email address:*
example@example.com
Do you consent to receiving text messages and emails from Avenues for Autism including appointment reminders and instructions on scheduling?*

YesNo (please call our office to discuss)
For identity verification purposes, please upload a copy of the client's driver's license. *

Cancelof

Name of client's legal guardian:*

First NameLast Name
Relationship to client:*

Biological parentAdoptive parentLegal guardianOther
Legal guardian's address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal guardian's telephone number:*
Please enter a valid phone number.
Legal guardian's email address:*
example@example.com
Do you consent to receiving text messages and emails from Avenues for Autism including appointment reminders and instructions on scheduling?*

YesNo (Please call our office to discuss)
For identity verification purposes, please upload a copy of the legal guardian's driver's license. *

Cancelof

Please identify an emergency contact. This does not give Avenues for Autism permission to discuss details relating to your treatment with this individual. This information is only used if a medical or behavioral health emergency arises during a session.
Emergency contact name:*

First NameLast Name
Emergency contact's phone number:*
Please enter a valid phone number.
Relationship to client:*

ParentSpouseChildFamily memberFriendOther

Relationship between client and the subscriber of the insurance:*

Subscriber is the client's parent/guardianSubscriber is the client's spouseOther
Subscriber's legal name:*

First NameLast Name
Subscriber's date of birth:*

MonthDayYear
Date
Subscriber's legal sex (required by insurance):*

MaleFemale
Subscriber's address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber's phone number:*
Please enter a valid phone number.
Subscriber's employer:*

Front of insurance card: *

Cancelof
Back of insurance card: *

Cancelof
If client has secondary insurance, upload front of secondary insurance card:

Cancelof
If client has secondary insurance, upload back of secondary insurance card:

Cancelof

Name of person completing this form: *

First NameLast Name
Who referred you to our services? *
Please provide any additional information here. We look forward to speaking with you.
Should be Empty: