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Massachusetts Autism Treatment Services Social Skills Request Form
*All groups are provided virtually and in English
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:
*
Insurance ID:
*
Primary Insurance Type (If Commercial - please submit a photo copy of the insurance form):
*
MassHealth Standard - Beacon
MassHealth Standard - Tufts
MassHealth Standard - MBHP
MassHealth Standard - Wellsense
MassHealth Standard - Mass General Brigham
BCBS
Tufts (Commercial)
Beacon (Commercial)
Optum (Harvard Pilgrim)
Optum (United HealthCare)
Optum (UBH)
Other
If able please upload a picture of the front and back of your insurance card
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Policy Holder:
*
First Name
Last Name
Policy Holder Date of Birth:
*
-
Month
-
Day
Year
Date
Form Respondent Name:
*
First Name
Last Name
Form Respondent Phone Number:
*
Please enter a valid phone number.
Form Respondent Relationship to Client:
*
Form Respondent Email:
example@example.com
Primary Contact for Client:
*
First Name
Last Name
Relationship to Client:
*
Legal Guardian:
*
Yes
No
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Number:
Please enter a valid phone number.
Is Client currently receiving insurance-funded ABA services?
Please Select
Yes
No
If yes, where?
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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Which of our social skills groups would the client be interested in?
Elementary Age Social Group (Ages 5-10)
Pre-Teen Social Group (Ages 10-14)
Teen Social Group (Ages 15-18)
Girls Social Group (Ages 10-16)
Gamer Social Group (Age 13+)
Build Social Group (Ages 8-12)
Arts & Crafts Social Group (all ages)
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