Client Referral Form
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's Information
Child's Name
First Name
Last Name
Gender?
Male
Female
Non-binary
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Care Provider
Name of Primary Care Provider
Primary Care Provider Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Care Provider Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/ Guardian Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Referral Source Information
Name of Referral Source
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Insurance Information
Who is your Primary Insurance Carrier?
If Medicaid, Name of Medicaid Carrier. (United Healthcare, Aetna, Optima etc.)
Diagnosis Information
Does the child have a diagnosis of Autism Spectrum Disorder?
Yes
No
Do you have a service order/ referral for Autism Services from a doctor?
Yes
No
If yes, do you have a copy of the diagnostic evaluation which states this?
Yes
No
Does the child use spoken language to communicate?
Yes
No
Uses AAC/device
Uses sign language
Uses gestures/pictures
Other
Please list any additional diagnoses. (ADHD, ODD, EBD, Anxiety, OCD)
Please list any and all current medications.
Submit
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