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

ABA Therapy Request

Please answer the questions in this form as best you can. Answering these questions will help us to make sure we give you the most exact info about our waitlist. Someone from Born to Blossom will call or email you at least 2 business days after you turn in this form. They will give you more info.
Important Note Before You Begin

It is important that you look through the whole form to make sure you have the papers you’ll need to turn in this form. Make sure you don’t close the tab this form is in if you need to go do something else. The form won’t save and you will have to start all over again. Make sure you have these things before you start working on this form: The patient’s insurance card (for Medicaid, it should be the child or adult you are turning in the form for. For Blue Cross Blue Shield [BCBS], it may be your info); the most recent physical for the patient (if you have Kansas Medicaid, it has to be on a ‘KanBeHealthy’ form or insurance will deny ABA therapy); the patient’s diagnosis report (it has to be the whole report, not just the page that says they have Autism, or insurance will deny ABA therapy); and the patient’s Individualized Education Program (IEP) or 504 Plan, if they have one from their school. If you don’t turn in these papers with the form, we can’t put you on the waitlist. Make sure you have them before you get started!
Client Demographic Information

Please tell us as much as you can so we can get started. Thanks!
Name of Person Filling out the Form

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

Other
Contact Email Address
We use email a lot to talk to you during the therapy process. Please give us an email address that you check a lot. This will help us if we need to get more papers or info from you. This is also how we’ll talk to you about scheduling things and give you updates.
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 drop their autism diagnosis report here. It has to have all of the scores and tests that were done to show they have autism.

Don't have the whole report? That's okay! If you want, you can fill out a Release of Info (ROI) form and we can get it for you! Copy and paste this link into a new tab to do the right ROI form: https://www.borntoblossombehavioraltherapy.com/paperwork
Cancelof
Where are you requesting services?

Scheduling for ABA Therapy – (Most clients get 10-40 hours a week. Make sure you click all the boxes that you can do. We do 4 hour sessions, so make sure you can do the whole 4 hours).

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

Parent/Guardian Demographic Information

Please tell us as much as you can so we can get started. Thanks!
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 use email a lot to talk to you during the therapy process. Please give us an email address that you check a lot. This will help us if we need to get more papers or info from you. This is also how we’ll talk to you about scheduling things and give you updates.
Legal Guardian #1 Marital Status
Legal Guardian #1 Marital Status
Legal Guardian #1 Education Level
Do you or your child/adult have someone else who legally makes choices for them (such as medical choices)? If yes, please give us their info here. If no, just click ‘No’ in the drop down menu, then move on.
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 use email a lot to talk to you during the therapy process. Please give us an email address that you check a lot. This will help us if we need to get more papers or info from you. This is also how we’ll talk to you about scheduling things and give you updates.
Legal Guardian #2 Marital Status
Legal Guardian #2 Education Level
Insurance Information

Please give us all the insurance info you have for your child/adult here. If you don’t give us correct info and insurance cards, it may take longer to get therapy going or you/your child may have to pay for ABA therapy. To get us an ROI for you/your child/adult's insurance company, copy and paste this link into a new tab to do the right ROI form: https://www.borntoblossombehavioraltherapy.com/paperwork
Name of Insurance Provider
Name of Policy Holder (Note: For Medicaid, it should be the child or adult you are turning in the form for. For Blue Cross Blue Shield [BCBS], it may be your info):

First NameLast Name
Policy Holder Social Security Number (SSN; Note: For Medicaid, it should be the child or adult you are turning in the form for. For Blue Cross Blue Shield [BCBS], it may be your info):
Enter the Social Security Number W/Dashes here.
Policy Holder Date of Birth

MonthDayYear
Date
Member ID Number
Found on the front of the insurance card.
Member Group ID Number
Found on the front of the insurance card.
Please drop a clear, well-lit picture of the front of the insurance card here.

Please note, you will not be added to the waitlist without a clear copy of the insurance card.
Cancelof
Please drop a clear, well-lit picture of the back of the insurance card here.

Please note, you will not be added to the waitlist without a clear copy of the insurance card.
Cancelof
Do you or your child/adult have a second insurance? (This may be private insurance from your work or Medicaid). If yes, give us the info here. If no, just click ‘No’ in the drop-down menu, then move on. Note: If you have a second insurance and you do not tell us, you/your child may have to pay for ABA therapy.
Name of Policy Holder (Note: For Medicaid, it should be the child or adult you are turning in the form for. For Blue Cross Blue Shield [BCBS], it may be your info):

First NameLast Name
Policy Holder Social Security Number (SSN; Note: For Medicaid, it should be the child or adult you are turning in the form for. For Blue Cross Blue Shield [BCBS], it may be your info):
Enter the Social Security Number W/Dashes here.
Policy Holder Date of Birth

MonthDayYear
Date
Member ID Number
Found on the front of the insurance card.
Member Group ID Number
Found on the front of the insurance card.
Please drop a clear, well-lit picture of the front of your child's second insurance card here.

Please note, you will not be added to the waitlist without a clear copy of the insurance card.
Cancelof
Please drop a clear, well-lit picture of the back of your child's second insurance card here.

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

Please fill out the following section with as much information as possible.
Who lives at home with your child/adult right now? (Please add the names of brothers and sisters, and how old they are.)
What language is used at home? Do you use more than one language? If yes, please list them here.
Do either of the child/adult’s birth parents have any known physical, mental, or learning disabilities? If yes, please tell us who they are and what they have.
Is there anything else you want to tell us about your child/adult or their family?
Developmental History Background

Please give us as much info about your child/adult’s age-related learning history as you can.
Pregnancy and Delivery
Were there any of these concerns during the pregnancy for this child/adult?
If you checked any of the boxes above, please give us more info about those concerns.
Age of birth-mother at the time of birth
Were there any post-birth needs for the mother or child/adult? (Oxygen, Longer Stay, Surgery, NICU, etc.)? If yes, what needs were there?
Are you worried about your child/adult’s sleeping or eating? If yes, what worries do you have? For adult clients, were there any worries with your sleeping or eating when you were a child? Are they still happening today?
Is there anything else you want to tell us about the child/adult’s age-related history?
Medical History

Please give us as much info as you can about the child/adult’s medical history and the health problems they are having right now. It’s really important for us to make sure there are no medical reasons for some behaviors and symptoms.
Name of Primary Care Doctor (PCP):

First NameLast Name
Primary Care Doctor (PCP) Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Care Doctor (PCP) Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Date of their last physical or wellness exam:

MonthDayYear
Date
Copy of a Current Physical (Note: People under the age of 21 who want/need ABA therapy have to have their physical on an official KanBeHealthy Physical Form to follow insurance rules.):

Note: If you do not give us a clear, easy-to-read physical form that was completed and marked with a date within the last 365 days, it may take longer to get therapy going. Call 620-330-9036 and our office can email the form we need to you before you call or see your doctor. You are also free to visit www.borntoblossombehavioraltherapy.com/paperwork , and we can send an ROI form to your doctor to get it for you!
Cancelof
Does the child or adult have any allergies? If so, what are they?
Has the child/adult had any big illnesses, been in the hospital, or had any surgeries? If yes, please tell us more.

Please list all of the child/adult’s current medicines. Please add the name, how much they take at a time, what times or how many times a day they take it, why they take it, and who prescribed it to them. Write N/A in the top row if they don’t take any medicines.

If you ran out of room above, please continue to list the child/adult's medicine information below.
Does the child/adult have history of any contagious diseases or other diagnoses we should know about?
Does the child/adult have a history of seizures? Please tell us what type and how they are treated. Also tell us what to do if a seizure happens (like if there’s a seizure plan from their doctor).
Educational History

Telling us about your child/adult’s school and learning history helps give us the info we need to plan our goals around. If there’s a question here that doesn’t apply to your child/adult, just write N/A.
Does your child/adult go to school?
Name of School
What grade is the child or adult in?
Name of Teacher

First NameLast Name
Did/Does your child/adult have an IEP or 504 Plan?
Is there anything else you want to tell us about your child/adult’s school or learning history?
Please drop your child/adult’s most up-to-date IEP/504 Plan here.

Don't have the whole report (or any part of it)? That's okay! If you want, you can follow the link below and fill out a Release of Info (ROI) form and we can get it for you! https://www.borntoblossombehavioraltherapy.com/paperwork
Cancelof
Therapy History

Please tell us as much as you can about the mental health, ABA, speech, OT, PT, and/or any other therapies that your child/adult has done or is doing. If they have done ABA therapy before now, please drop the most up-to-date plan from the ABA therapy place they last went to. If you don’t have the plan, you can fill out a release of info form and we can ask them to give it to us for you.
Has the child/adult ever had mental health services in the past, including old assessments?
If yes, please tell us the name of the person that your child/adult saw and what kind of therapy was done.
Has the child/adult had ABA therapy before? This also counts if they/you had parent training.
If yes, please tell us the name of the person that you/your child/adult saw and what kind of therapy was done.
Does the child/adult have speech, OT, or PT? Have they done any of these therapies in the past? (If no, you can skip the questions 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.
Do you want to tell us anything else about your child/adult’s therapy history?
Current Behavioral Concerns

Please tell us about problem behaviors that your child/adult has shown in the last 6 months.
Please pick from the menu what problem behaviors your child/adult has shown or done in the last 6 months:
Do they have any other behaviors that you are worried about and would like to tell us about?
How did you hear about us?
Legal Guardian Consent

The info I gave for me, my child, or the adult I filled this form out for is true and correct to the best of my ability. I am legally allowed to give this info to Born to Blossom.
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