General Bista Inquiry

1
What service location(s) are you interested in ?* This field is required.Select all that apply
Phoenix Clinic: 3201 W Peoria Ave Site B301 Phoenix, AZ
Alhambra District: 4730 West Campbell Ave, Phoenix, AZ 85031 (Alhambra Preschool Academy)
Chandler Clinic: 3910 S Alma School Rd Suite Chandler, AZ
Tempe Clinic: 5301 S McClintock Dr Tempe, AZ
Marana Clinic: 1625 W Ina Rd Suite 109 Tucson, AZ 85704
Sunnyside District: 5702 S Campbell Ave Tucson, AZ (Ocotillo Learning Center - SUSD)
Flagstaff District: 4005 E Butler Ave, Flagstaff, AZ 86004 (Knoles Elementary School)
Urbandale Clinic: 4370 114th St Urbandale, IA
North Atlanta Area: 12460 Crabapple Rd Alpharetta, GA
2
What services are you interested in at our Phoenix Clinic?Select all that apply
Applied Behavior Analysis (ABA)
Speech Therapy
Occupational Therapy
School Consultation
Parent Training/Family Coaching
Social Group
Feeding Therapy
AAC Device Evaluation
3
What services are you interested in at our Alhambra District site?Select all that apply
Applied Behavior Analysis (ABA)
School Consultation
Parent Training/Family Coaching
Social Group
4
What services are you interested in our Chandler area?Select all that apply
Applied Behavior Analysis (ABA)
Speech Therapy
Occupational Therapy
School Consultation
Parent Training/Family Coaching
Social Group
Feeding Therapy
AAC Device Evaluation
5
What services are you interested in at our Tempe Clinic?Select all that apply
Applied Behavior Analysis (ABA)
Speech Therapy
Occupational Therapy
School Consultation
Parent Training/Family Coaching
Social Group
Feeding Therapy
AAC Device Evaluation
6
What services are you interested in at our Marana Clinic?Select all that apply
Applied Behavior Analysis (ABA)
School Consultation
Parent Training/Family Coaching
Social Group
7
What services are you interested in at our Sunnyside District site?Select all that apply
Applied Behavior Analysis (ABA)
School Consultation
Parent Training/Family Coaching
Social Group
8
What services are you interested at our Flagstaff District site?Select all that apply
Applied Behavior Analysis (ABA)
School Consultation
Parent Training/Family Coaching
Social Group
9
What services are you interested at our Urbandale Clinic?Select all that apply
Applied Behavior Analysis (ABA)
School Consultation
Parent Training/Family Coaching
Social Group
10
What services are you interested in our North Atlanta Area?Select all that apply
Applied Behavior Analysis (ABA)
School Consultation
Parent Training/Family Coaching
11
¿Como se llama?
Primer Nombre
Apellido
12
¿Cuál es tu dirección de correo electrónico?* This field is required.
example@example.com
13
¿Cuál es tu número de teléfono?
Por favor ingrese un número de teléfono válido.
14
¿Quién es su proveedor de seguros?
Please Select
Please Select
Aetna
AHCCCS - United Community Plan
AHCCCS - Mercy Care
AHCCCS - AZ Complete Health
Blue Cross + Blue Shield
Cigna
TriCare
United HealthCare/Optum
15
What is your name?
First Name
Last Name
16
What is the client's name?
First Name
Last Name
17
What is your email address?* This field is required.
example@example.com
18
What is your phone number?
Please enter a valid phone number.
19
What is your address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
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Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
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Laos
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
20
What is the client's date of birth?* This field is required.
Date
Month
Day
Year
21
Who is your insurance provider?* This field is required.
Please Select
Please Select
Aetna
AHCCCS - United Community Plan
AHCCCS - Mercy Care
AHCCCS - AZ Complete Health
Blue Cross + Blue Shield
Cigna
TriCare
United HealthCare/Optum
Other
Private Pay
22
What is the insurance or form of payment? * This field is required.
23
Please tell us why you are seeking the selected service(s).
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Ok
24
Briefly describe the clients communication abilities & behavioral difficulties.Ex. Uses full sentences, uses an AAC device, engages in aggression 5x per week
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Ok
25
What time slots are you available for services? * This field is required.Select all that apply
26
Please upload any supporting documentation here:Photos of insurance cards, evaluations, diagnostic reports, IEPs, METs...etc.
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