Client Inquiry Form
Disclaimer: The information you provide in this form will be used only to respond to your inquiry. We do not share, sell, or use your personal information for marketing.
Name of Person Completing Form
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Date Completed
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-
Month
-
Day
Year
Date
Child's Full Name
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Child's Full Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Date of Birth
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MM/DD/YYYY
Child's Gender Identity:
Male
Female
Non-Binary
Rather Not Say
Primary Caregiver/ Parent's Full Name
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Primary Caregiver/ Parent's Email
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Primary Caregiver/ Parent's Phone Number
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Additional Caregiver/ Parent's Name
Additional Caregiver/ Parent's Email
Additional Caregiver/ Parent's Phone Number
Healthcare Information
Primary Healthcare Insurance
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Health Plan Member ID
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Policy Group Number
Policyholder's Name (Primary)
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Policyholder's Date of Birth
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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
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Primary Care Provider Provider Phone Number
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Health Clinic Fax Number:
Name of ASD Diagnosing Provider
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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 (put in full times of availability Ex: 10am-3pm)
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Rows
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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