Patient Interest Form
What services are you interested in?
*
Please Select
In-Home ABA Therapy
Infinity Academy (Early Intervention Clinic)
Infinity Social Network (Teens/Young Adults)
Family Therapy
Speech Therapy
Name of Person Completing Form
*
First Name
Last Name
Relationship to Patient
*
Patient Full Name
*
First Name
Middle Name
Last Name
Patient Sex
*
Please Select
Male
Female
Patient Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Age
*
Patient Diagnosis
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Date of Diagnosis
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name Primary/Referring Doctor
*
Does the patient currently attend school?
*
Yes
No
Name of Parent or Legal Guardian
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What funding source will you be using?
*
Insurance, Medicald, Private Pay, Other
What is the name of your Insurance Company or Medicaid plan?
*
If you are a Medicaid member, please type in your Medicaid ID number:
Do you have more than one funding source? How many and which ones?
*
Insurance Card
Browse Files
Drag and drop files here
Choose a file
If you would like us to complete an insurance eligibilty verification at this time, please upload a copy of the front and back of your insurance card.
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of
Challenging Behaviors
*
Aggression
Destructive Behaviors
Self-Harming Behaviors (hitting self, bitting self, etc.)
Rigidity/Inflexibility
Elopement
Noncompliance
Tantrums/Meltdowns
Pica (ingesting non-food item)
Safety Concerns in Public
Other
Areas of Concern
*
Language Delays/Deficits
Academic
Attention
Limited Reinforcers or Preferred Activities
Toilet Training
Food Selectivity
Activities of Daily Living (dressing, eating, chores)
Vocational Skills
Social Skills/Peer Interactions
Sensory
None
Other
Availability for Sessions (Clinic program runs from 9-5pm and Teens Program T/Th evenings only)
*
Rows
Morning (9am-12pm)
Afternoon (12pm-3pm)
Evening (3pm-7pm)
Clinic Program (9am-5pm)
Not available
Teens
Monday
Tuesday
Wednesday
Thursday
Friday
Additional Information
*
How did you hear about us?
*
Submit
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