Meliora Health Intake Form
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  • Spanish (Latin America)

  • Meliora Health Intake Form

    The purpose of this form is to collect information that will be shared with the provider(s) that will be working with the patient. Please note you will need the following to complete this form: the patient's insurance card(s), proof of guardianship (if completed by someone other than the patient or a biological parent), and proof of autism and/or ADHD diagnosis (depending on appointment type).
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  • Meliora Health is only able to provide services for patients between 16 months and 21 years of age.

  • Meliora Health is only able to provide ADHD services for patients between 5 and 21 years of age. Please deselect ADHD Evaluation or update Patient Date of Birth.

  • Our rates are as follows:

    Diagnostics

    - Autism Evaluation: $1,500
    - ADHD Evaluation: $1,500
    - Combined Autism and ADHD Evaluation: $2,500

    ABA Order Visit: $250

    Developmental Pediatrics

    - Initial Appointment with NP (1 hour): $300
    - Followup Visits with NP (30 minutes): $200

    - Initial Appointment with MD (1 hour): $400
    - Followup Visits with MD (30 minutes): $250

    We will require a card on file at the time of scheduling an appointment.

    A comprehensive report will be provided and posted to your patient portal. If you or your child is recommended for ABA therapy we can provide that order for you. For Social Skills Support pricing, please give us a call at 855-675-1849.

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  • Patient Information

    Demographics
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  • Areas of Concern

    Reason you are seeking services from Meliora Health

  • Education & Services

  • Medical History

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  • You're almost there!

    After pressing submit, you will be redirected to our consent forms.

    Consent forms will need to be signed in order to schedule your appointment(s).

    Please check your email for next steps.

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