Patient Referral Form

Patient Referral Form

Phone: (281) 815-5782 Fax: (346) 209-2029 admin@cuspbehavioral.com
This form must be completed and submitted to Cusp Behavioral Health by the office of a developmental pediatrician, neurologist, psychiatrist, licensed psychologist, or an interdisciplinary diagnostic team. If you are a parent/guardian or other provider seeking to access ABA services or refer a client to Cusp Behavioral Health, please contact us at (281) 815-5782 or visit our website at www.cuspbehavioral.com.

Clinical Information
Client Diagnosis Code(s):
Date of Diagnosis

MonthDayYear
Date
Diagnostic Severity (per DSM-5 Diagnostic Criteria):

Level 1: Requiring SupportLevel 2: Requiring Substantial SupportLevel 3: Requiring Very Substantial Support
Diagnostic Report

Cancelof
To request authorization for an initial ABA assessment and ongoing treatment, some insurance providers require diagnosing clinicians to sign a prior authorization form which indicates agreement with the requested treatment hours. This form will be faxed to your office once eligibility has been determined and all required documents have been received. The prior authorization form must be returned as soon as possible. If you have any questions, please contact our office at (281) 815-5782.

Thank you for partnering with Cusp Behavioral Health!
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