Client Inquiry Form
Name of Person Completing Form
*
Date Completed
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-
Month
-
Day
Year
Date
Child's Full Name
*
Child's Full Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Date of Birth
*
MM/DD/YYYY
Child's Gender Identity:
Male
Female
Non-Binary
Rather Not Say
Primary Caregiver/ Parent's Full Name
*
Primary Caregiver/ Parent's Email
*
Primary Caregiver/ Parent's Phone Number
*
Additional Caregiver/ Parent's Name
Additional Caregiver/ Parent's Email
Additional Caregiver/ Parent's Phone Number
Healthcare Information
Primary Healthcare Insurance
*
Health Plan Member ID
*
Policy Group Number
Policyholder's Name (Primary)
*
Policyholder's Date of Birth
*
Front Image of Insurance Card
*
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Back Image of Insurance Card
*
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If Policyholder's Address is different than child's primary address, please complete the following section. Otherwise move on to the next question.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Insurance
Member ID for Secondary Insurance
Subscriber's Name (Secondary)
Date of Birth for Secondary Policyholder
Secondary Insurance Card (Front & Back)
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Medical History
Primary Care Provider
*
Primary Care Provider Provider Phone Number
*
Health Clinic Fax Number:
Name of ASD Diagnosing Provider
*
Hospital/ Clinic Name
Date of ASD Diagnosis
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Diagnosed Level of ASD:
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Level 1
Level 2
Level 3
Unknown
Please list any additional diagnoses or medical conditions:
Diagnosing Information: To receive ABA services, a REFERRAL/PRESCRIPTION AND DIAGNOSTIC REPORT for Applied Behavior Analysis is required, accompanied by a diagnosis of Autism Spectrum Disorder and a comprehensive evaluation from a qualified specialist. Whether you choose to upload these documents now or submit them later, please note that we cannot advance your application until we have received these essential documents.
*
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Legal Guardianship and Consent
List which guardian or parent(s) have legal authority to make medical decisions for this child:
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Mother
Father
Both
Other
ABA Services
Are you willing to participate in a weekly or monthly Family Guidance/Parent Training session, which might be scheduled outside of the standard therapy hours?
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Yes
No
Is your child currently enrolled in services with another ABA provider?
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Yes
No
If yes, please provide the name:
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What are your primary areas of concern regarding your child’s ASD diagnosis?
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Communication Skills
Behavioral
Social Skills
Daily Living Skills
Please share any extra detail that may aid in setting up services for your child.
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Availability for Services
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Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
I acknowledge that I have the option to request a copy of this form in a different language. For assistance, I can contact info@alwaysshiningaba.com
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Yes
Submit
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