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New Hampshire Autism Treatment Services Referral Form
About the Client
Date:
*
-
Month
-
Day
Year
Date
Client's Legal Name:
*
First Name
Last Name
Known As:
Gender Identity:
*
Female
Male
Transgender
Other
Date of Birth:
*
-
Month
-
Day
Year
Date
Language Needed for Services:
*
Would family be interested in Pride ABA services? (Specialty services for LGBTQ+ youth and families)
*
Yes
No
Insurance Information
Primary Insurance Company Name
*
Insurance ID:
*
If able please upload a picture of the front and back of your insurance card
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Policy Holder (if different than client):
First Name
Last Name
Policy Holder Date of Birth:
-
Month
-
Day
Year
Date
Referral Contact Information
Legal Guardian:
*
First Name
Last Name
Legal Guardian Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Legal Guardian's Email:
example@example.com
Legal Guardian's Relationship to Client:
Legal Guardian's Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DCYF CPSW (if applicable):
First Name
Last Name
DCYF CPSW Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
DCYF Supervisor (if applicable):
First Name
Last Name
DCYF Supervisor Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Person Making Referral (if not DCYF)
First Name
Last Name
Referent Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Referent Relationship to Client:
Referent Agency or Organization Affiliation:
Other Information
Relevant Medical Information:
Does this client have an Autism Spectrum Disorder diagnosis?
Please Select
Yes
No
Unsure
School Information (Location, Grade, Special Education/Current IEP, Academic/Social Performance, Behaviors):
Other Information:
We will need the following documentation to consider the referral complete: An evaluation assigning or confirming ASD diagnosis (containing either the ADOS, CARS, or GARS tests); An active and signed IEP; A recent well child visit summary completed within the last year from PCP; Letter of medical necessity recommending in-home ABA services from PCP
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Submit
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