Request for services

Request for Services

Reset Behavior LV
Child's Name:*

First NameLast Name
Email Address:*
example@example.com
Contact Number:*
Please enter a valid phone number.
Client's Date of Birth:*

MonthDayYear
Date
Parent/Guardian Name:*

First NameLast Name
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a Diagnosis of Autism Spectrum Disorder?*

YesNoOther
If you do not have a Diagnosis of Autism Spectrum Disorder are you interested in receiving information about our ADOS-2 Diagnosis Assessment?

YesNo
To Fast Track the Authorization process:

(Optional)
To expedite the waitlist process:

Attach:

1. Front and Back of your Insurance Card(s).

2. Referral for ABA Services from your primary care physician. (Straight Medicaid patients please attach your FA-11F form).

3. The child's original Diagnosis Report.

Failure to provide this information may delay the authorization process.

Thank You!
Diagnosis:
Autism Spectrum Disorder
Date of Diagnosis:
When Paperwork was signed by the provider
Diagnosing Doctor:
Diagnosing Paperwork

Please upload your paperwork given to you by your doctor when you received your ASD Diagnosis.
Cancelof
Referral Paperwork

Please upload your paperwork given to you by your doctor. Example referral for ADOS-2 Assessment, ABA services or FA-11(Medicaid).
Cancelof
Primary Insurance:*
Policy Number:
Group Number:
Primary Insurance Holder:
Policy Holder's Date of Birth:

MonthDayYear
Date of Birth
Do you have a Secondary Insurance?

YesNo
Secondary Insurance:
Policy Number:
Group Number:
Primary Insurance Holder:
Policy Holder's Date of Birth:

MonthDayYear
Date of Birth
Secondary Insurance Cards:

Front and the Back of the Card
Cancelof
What services are you interested in?
What is your preferred location for services?

In-HomeIn-ClinicHybrid (home and clinic)
What is your preferred time block for services?

Morning (9am - 2pm)Afternoon (3pm - 6pm)Other
Comments
Date

MonthDayYear
Date
Parent/Guardian Signature:

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Should be Empty:

Request for Services

To Fast Track the Authorization process: