Prosper Health - Intake Forms

Prosper Health - Assessment Intake Forms

Please complete all of the attached forms. Note: all of the forms must be completed to submit. We estimate the forms take ~10-15 minutes in total.

Release of Information
As part of the assessment process, Prosper Health requires the input of 1-2 people who know you. This helps our psychologists learn more about you, how you behave, and how you communicate.

By filling out this form, you give Prosper permission to contact the individuals listed below and involve them in the assessment process by completing rating forms that will be used in your assessment. These forms must be completed prior to your assessment.

One questionnaire should go to a person who can tell us more about you during your childhood / development (ages 3-6). This is usually a parent, guardian, or sibling who is more than five years older than you. Choose someone who knew you and your daily behavior well and can speak about any autism signs that were evident back then.

The other questionnaires will go to a person who can tell us more about you now. This is usually a partner, friend, or family member. Choose someone who knows your day-to-day routines and can report any autism-related signs that they see.
Your Name*

First NameLast Name
Your Email Address*
example@example.com
Send and Receive
Assessment rating forms
To / from the following person who knows me from ages 3-6 during childhood / development (parent, family member, guardian):

Having a person to fill out these forms, who is more than 5 years older than you, is highly suggested as part of the assessment process. We understand that some people may not have someone who fits this description. In these cases, please reach out to help@prosperhealth.io and we can discuss options! If phone number is international, just use your domestic phone number instead.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relation*
Yes, I confirmNo, I do not confirm
To / from the following person who knows me now / in adulthood:
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relation*
I understand that this information may be protected by Title 45 (Code of Federal Rules of Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 42 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. I further understand that the information disclosed to the recipient may not be protected under these guidelines if they are not a health care provider covered by state or federal rules.I understand that this authorization is voluntary, and not a condition for treatment, payment, enrollment or eligibility for benefits, and I may revoke this consent at any time by providing written notice, and after (some states vary, usually 1 year) this consent automatically expires. I have been informed what information will be given, its purpose, and who will receive the information. I understand that I have a right to receive a copy of this authorization. I understand that I have a right to refuse to sign this authorization.If you are the legal guardian or representative appointed by the court for the client, please attach a copy of this authorization to receive this protected health information.*

I consent

Prosper Health - Assessment Intake Forms

Release of Information

To / from the following person who knows me from ages 3-6 during childhood / development (parent, family member, guardian):

To / from the following person who knows me now / in adulthood:

Clinical Background

Health and Lifestyle

Autism / Development Background

Miscellaneous