Born to Blossom ABA Therapy Request

ABA Therapy Request

Important Note Before You Begin

Client Demographic Information

ABA Therapy Services

Parent/Guardian Demographic Information

Insurance Information

Family History Information

Developmental History Background

Medical History

Educational History

Therapy History

Current Behavioral Concerns

Legal Guardian Consent

Pregnancy and Delivery

Early Childhood Development

ABA Therapy Request

Please fill out the following form to the best of your abilities to help guide our intake and waitlist process. A member of our team will be in contact with you within 48 business hours of your request for services to provide you with more information.
Important Note Before You Begin

We encourage you to scroll through the entire document and note what information and files you will need to submit this request, as it will not save if you have to step away from it. Please complete in its' entirety and submit all in one sitting. Also, note that we require copies of the patient's insurance card, most recent physical (or KBH if Kansas Medicaid), and IEP/504 as applicable. If you do not submit these documents with your request we will be unable to add you to the waitlist! Please make sure you gather these prior to starting the form.
Client Demographic Information

Please provide as much information as possible to help guide the initial steps of the therapy process. Thank you!
Name of Individual Completing the Form

First NameLast Name
Who are you filling the form out for?

Other
Contact Email Address
We highly utilize email to communicate during the treatment process. Please provide us with the best email address to contact you at regarding paperwork, scheduling, and treatment progress.
Child/Adult's Legal Name

First NameLast Name
Child/Adult's Date of Birth

MonthDayYear
Date
If filling out for a minor child, is the child adopted or in foster care?
Child/Adult's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Child/Adult's Birth Sex
Child/Adult's Gender
Child/Adult's Pronouns
Child/Adult's Race/Ethnicity
Child/Adult's Religion/Spirituality
ABA Therapy Services
What diagnosis are you seeking ABA therapy for?
Please upload their formal Autism Evaluation Report (Report should contain information/scores related to the CARS, ADOS-2, ADI-R, etc.)

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Where are you requesting services?

Availability for Services- (Keeping in mind that most clients receive 10-40 hours per week of therapy, please select any/all time slots you are available for. We run our clinics in blocks, so you must be available for the entire block.)

Rows	Monday	Tuesday	Wednesday	Thursday	Friday
8:45 am- 12:30 pm
12:30 pm- 4:15 pm

Parent/Guardian Demographic Information

Please provide as much information as possible to help guide the initial steps of the therapy process. Thank you!
Legal Guardian #1 Legal Name

First NameLast Name
Relationship to Client
Legal Guardian #1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Guardian #1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Legal Guardian #1 Email Address
We highly utilize email to communicate with caregivers throughout the therapy process. Please provide us with the best email address to contact you at regarding paperwork, scheduling, and treatment.
Legal Guardian #1 Marital Status
Legal Guardian #1 Marital Status
Legal Guardian #1 Education Level
Do you or your child/adult have another legal guardian responsible for making their medical decisions? If so, please provide that information below. If they do not have other legal guardians, you may indicate so in the drop-down and proceed on to the next section.
Legal Guardian #2 Legal Name

First NameLast Name
Relationship to Client
Legal Guardian #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Guardian #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Legal Guardian #2 Email Address
We highly utilize email to communicate with caregivers throughout the therapy process. Please provide us with the best email address to contact you at regarding paperwork, scheduling, and treatment.
Legal Guardian #2 Marital Status
Legal Guardian #2 Education Level
Insurance Information

Please provide all relevant insurance information for your child/adult below. Failure to submit the accurate, current cards may result in a delay in services and/or the client being responsible the cost of services.
Name of Insurance Provider
Name of Policy Holder (Note: This will be the child/adult for Medicaid, but may be the parent/guardian for BCBS)

First NameLast Name
Policy Holder Social Security Number (Note: This will be the child/adult for Medicaid, but may be the parent/guardian for BCBS)
Enter the Social Security Number W/Dashes here.
Policy Holder Date of Birth

MonthDayYear
Date
Member Identification Number
Found on the front of the insurance card.
Member Group ID Number
Found on the front of the insurance card.
Please upload a copy of the front of your child's current insurance card.

Please note, you will not be added to the waitlist without a clear copy of the insurance card.
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Please upload a copy of the back of your child's current insurance card.

Please note, you will not be added to the waitlist without a clear copy of the insurance card.
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Do you or your child/adult have secondary coverage? (i.e. Medicaid and Private Insurance.) If so, please provide that information below. If you do not have secondary coverage, you may indicate so in the drop-down and proceed on to the next section. Please note, failure to report secondary insurance information may result in being responsible for the cost of services.
Name of Policy Holder (Note: This will be the child/adult for Medicaid, but may be the parent/guardian for BCBS)

First NameLast Name
Policy Holder Social Security Number (Note: This will be the child/adult for Medicaid, but may be the parent/guardian for BCBS)
Enter the Social Security Number W/Dashes here.
Policy Holder Date of Birth

MonthDayYear
Date
Member Identification Number
Found on the front of the insurance card.
Member Group ID Number
Found on the front of the insurance card.
Please upload a copy of the front of your child's current secondary insurance card.

Please note, you will not be added to the waitlist without a clear copy of the insurance card.
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Please upload a copy of the back of your child's current secondary insurance card.

Please note, you will not be added to the waitlist without a clear copy of the insurance card.
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Family History Information

Please fill out the following section with as much information as possible.
Who currently lives at home with the child or adult? (Include sibling names and ages, please.)
What languages are spoken in the home?
Do either of the biological parents have any known physical, mental, or learning disabilities? If so, please list who it is and what the condition is.
Is there anything else about the child or adult's family that you would like for us to know?
Developmental History Background

Please provide as much information about the child or adult's developmental background as possible.
Pregnancy and Delivery
Where there any of the following concerns during the pregnancy?
If you selected any concerns in the previous section, please provide detailed information on those concerns.
Age of biological mother at time of birth.
Any post-birth needs for mother or child (oxygen, extended stay, surgery, NICU, etc.)? If so, what were those needs?
Early Childhood Development

Select any of the following developmental milestones that the child or adult were delayed in demonstrating or missed entirely.
Typical Two Month Milestones
Typical Four Month Milestones
Typical Six Month Milestones
Typical 9 Month Milestones
Typical 12 Month Milestones
Typical 15 Month Milestones
Typical 18 Month Milestones
Typical 2 Year Milestones
Typical 30 Month Milestones
Typical 3 Year Milestones
Typical 4 Year Milestones
Typical 5 Year Milestones
Do you have any concerns with your child's sleeping or eating? If so, what are those concerns? For adult clients, were there concerns with your sleeping or eating patterns as a child? Are they still occurring today?
Is there anything else regarding the child or adult's developmental history that you'd like us to know?
Medical History

Please provide as much information as possible about the child or adult's medical history and current health status. Ruling out medical causes for certain symptoms is highly important in the treatment process.
Name of Primary Care Physician

First NameLast Name
Primary Care Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Care Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last Physical Exam/Wellness Check

MonthDayYear
Date
Copy of Current Physical (Note: Individuals under the age of 21 applying for ABA services must have their physical on an official KanBeHealthy Physical Form per insurance requirements.)

Note: Failure to provide a clear, legible physical form dated within the last 365 days will result in a delay in being placed on the waitlist for services. Please call 620-330-9036 to have the form emailed to you prior to talking with your doctor.
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Does the child or adult have any allergies? If so, what are they?
Has the child or adult had any significant illnesses, hospitalizations, or surgeries? If so, please explain.

Please list all of the child or adult's current medications, including name, dosage, time(s) of day given, purpose of the medication, and who prescribed the medication. Write N/A in the top row if they are not on medications.

If you ran out of room above, please continue to list the child or adult's medication information below.
Does the child or adult have any history of infectious diseases or other diagnoses we should know about?
Does the child or adult have a history of seizures? Please include the type and current treatment if so.
Educational History

Providing information about the child or adult's educational history helps to provide background information needed for treatment planning. If the field does not pertain to the individual at this time, please write N/A.
Does the child or adult attend school?
Name of School
What grade is the child or adult in?
Name of Teacher

First NameLast Name
Did/Does the child or adult have an IEP/504 plan?
Anything else you would like us to know about the child or adult's educational or school history?
Please upload the child or adult's most recent/current IEP/504 plan.

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Therapy History

Please provide us with as much detail as you can surrounding the mental health, ABA, speech, OT, PT, or other relevant therapeutic services that the child or adult has received. If they have received ABA therapy prior to this request, we will request a copy of their most recent treatment plan or a release of information to obtain that report from the provider.
Has the child or adult received mental health services in the past, including previous assessments?
If yes, please provide the name of the provider and the service the child or adult received.
Has the child or adult received ABA therapy services in the past, including parent coaching services?
If yes, please provide the name of the provider and the service the child or adult received.
Does the child or adult receive speech, occupational therapy, physical therapy? Have they received them in the past? (If no, please skip the provider section below.)
Which therapy has the child or adult received?
Name of Provider (Speech)

First NameLast Name
Provider Address (Speech)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Speech)
Please enter a valid phone number.Format: (000) 000-0000.
Name of Provider (Occupational Therapy)

First NameLast Name
Provider Address (Occupational Therapy)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Occupational Therapy)
Please enter a valid phone number.Format: (000) 000-0000.
Name of Provider (Physical Therapy)

First NameLast Name
Provider Address (Physical Therapy)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Physical Therapy)
Please enter a valid phone number.Format: (000) 000-0000.
Is there anything else you'd like our team to know about the child or adult's therapy history?
Current Behavioral Concerns

Please provide us with information on barrier behaviors that the child or adult has engaged in in the previous six month period.
Please select if the child or adult currently engages in the behavior or has engaged in the behavior in the last six months:
Are there any other behavioral concerns you'd like our team to know about?
How did you hear about our services?
Legal Guardian Consent

The information I have provided for myself, my child, or the adult is accurate and true to the best of my ability and I am legally authorized to disclose this information.
Parent/Guardian Signature
Should be Empty:

Medication Name

Time of Day Given

Purpose of Medication

Who prescribed the medication?

When was the med first prescribed?

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5