Autism Counseling & Support Services

Which service are you interested in?

Counseling/Skill Building/Group TherapyApplied Behavior Analysis (ABA)
What are your goals for therapy?*

Diagnostic Report

Insurance requires prior authorization for all ABA services. Please upload a copy of the diagnostic report confirming a medical diagnosis of autism.
File Upload*

Cancelof

Is the client a minor (under the age of 18) or an adult under legal guardianship?*

Client is a minorClient is an adult under legal guardianshipClient is an adult

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?*

Self-Referred/Online SearchCurrent/Previous Avenues for Autism ClientAvenues for Autism EmployeeHealthcare Provider (doctor, therapist, etc.)Community Resource (Board of DD, Ability Center, etc.)Other
Please provide any additional information here. We look forward to speaking with you.
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Diagnostic Report