Atlantis PBS Referral Sheet

Atlantis Positive Behavior Services

Referral Sheet
Thank you for choosing to refer to Atlantis PBS for ABA services! We deeply appreciate your trust and confidence in our team.

Atlantis Positive Behavior Services is committed to delivering compassionate, reliable, and ethical care. Our approach is rooted in authenticity and empathy, ensuring that every individual we support receives the highest standard of service.

Should you have any questions or need further assistance, please don’t hesitate to reach out to admin@atlantispbs.com. We look forward to the opportunity to make a positive impact in the community.
Today's Date

MonthDayYear
Date
Client Name

First NameLast Name
Client's DOB

MonthDayYear
Date
Guardian Name

First NameLast Name
Guardian's relation to client
Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guardian Email
example@example.com
Referral Source
Caseworker

First NameLast Name
Referral Source Email
example@example.com
Referral Source Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary insurance and number
Secondary insurance and number
Client's Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Access to WIFI in the home?
Client's School
NA if not attending
Client's Grade
Is the client in SPED?
Client's Primary Physician and Practice
Client's Specialist and Practice
Please list any medications the client currently takes
Please list any known allergies
NA if none
Client's diagnosis/diagnoses
Explain present behavioral concerns

Select the client's availability for services

Rows	8am - 12pm	12pm - 4pm	4pm - 8pm
Monday
Tuesday
Wednesday
Thursday
Friday

Any other relevant information
Should be Empty:

Atlantis Positive Behavior Services