Registration Form
Satyaluna Health & Wellness
Patient Info
Patient Name
*
First Name
Middle Initial
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient Sex
*
Please Select
Male
Female
N/A
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Phone Number
*
Please enter a valid phone number.
Patient Email
example@example.com
Patient SSN
Preferred Language
*
Marital Status
*
Single
Married
Divorced
Widowed
Responsible Party Information
Please add both Parents / Legal Guardians (if applicable)
Legal Guardian Name
*
First Name
Middle Initial
Last Name
Relationship to Patient
*
Legal Guardian Phone Number
*
Legal Guardian E-mail
*
example@example.com
Legal Guardian Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Legal Guardian Name
First Name
Middle Initial
Last Name
Legal Guardian Phone Number
Please enter a valid phone number.
Legal Guardian Email
example@example.com
Legal Guardian Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Information
Please add both Insurance (if applicable)
Primary Insurance
*
Policy Holder
*
Insured's Date of Birth
*
-
Month
-
Day
Year
Date
Insured SSN
*
Insured Employer's Name
*
Policy Number
*
Group Number
*
Secondary Insurance
Policy Holder
Insured's Date of Birth
-
Month
-
Day
Year
Date
Insured SSN
Insured Employer's Name
Policy Number
Group Number
Upload ALL Insurance Cards Front and Back
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of
Diagnosis (Autism Spectrum Disorder, ADHD, Etc)
*
Put N.A. if not applicable
Name of the Doctor, Psychologist, Etc that Diagnosed
*
Put N.A. if not applicable
Date the Diagnosed
*
-
Month
-
Day
Year
Put 01/01/2025 if not applicable
Upload the Diagnostic Report (i.e. Vanderbilt Report)
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of
School Information
Is the Patient currently enrolled in a school or daycare?
*
Yes
No
School Name
*
Grade level
*
School Hours
*
Does the Patient have an IEP?
*
Yes
No
Other Therapies
Is the patient in any other therapies?
*
Yes
No
Please list all other therapies the patient currently attends with days and times.
*
In case of emergency
Emergency Contact:
*
First Name
Last Name
Relationship
*
Contact Number
*
Taking any medications, currently?
*
Yes
No
Please list it here
*
Consent to Treat
I give permission for Satyaluna Health & Wellness to render to me (and/or my named dependent above) ABA treatment. I also understand I have the right to refuse treatment and to discuss all treatment programs with my assigned Behavior Analyst.
Assignment of Benefits
I request that payment of authorized Medicare, Medicaid and all other insurance benefits be made on my behalf to Satyaluna Health & Wellness for any services provided to me and/or my dependents. I authorize any holder of medical information about me and/or my dependents to be release to the appropriate entity and its gents any information needed to determine the benefits payable for related and/or provided services. I understand that I must pay my share of the costs, including co-pays and deductibles at each visit. Furthermore, if my insurance does not pay or I do not have insurance, I must pay for the cost of these services.
Patient Signature or Patient Representative
*
Representative Relationship to patient
*
Self
Parent or Legal Guardian
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