Client Contact Information
Individual Full Name
*
First Name
Middle Name
Last Name
Individual Date-of-Birth
*
-
Month
-
Day
Year
Date
Individual Gender
*
Please Select
Male
Female
Prefer not to select
Primary Care Provider (PCP)
Does the individual have a diagnosis of Autism?
*
Please Select
Yes
No
If no- What is their diagnosis?
Is the child in school?
*
Please Select
Yes
No
Contact Information
Your Name
*
First Name
Middle Initial
Last Name
Relationship to Individual
*
Please Select
Mother
Father
Legal Guardian
Other
Are you the person we need to contact regarding services?
*
Please Select
Yes
No
If no, then please provide the information for the person you are referring.
Primary Caregiver Phone Number:
Please enter a valid phone number.
Primary Caregiver Email
*
example@example.com
Address of Primary Caregiver:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Will the individual use insurance for services?
*
Please Select
Yes
No
Is there more than one insurance policy for the individual?
*
Please Select
Yes
No
If yes, then populate secondary insurance carrier and policy holder DOB questions. If no, then just populate primary insurance information
Primary Insurance Carrier
*
Please Select
BlueCross BlueShield
United HealthCare
Wellpoint
Cigna
Aetna
Other
Member ID:
Primary Insurance
Primary Insurance Policy holder DOB
*
-
Month
-
Day
Year
Date
Secondary Insurance Carrier (if applicable, however not required)
*
Please Select
BlueCross BlueShield
United HealthCare
Wellpoint
Cigna
Aetna
Other
Secondary Member ID: (if applicable, however not required)
Secondary Insurance
Secondary Insurance Policy holder DOB (if applicable, however not required)
*
-
Month
-
Day
Year
Date
Back
Next
Therapy Screening
What is your #1 concern or goal in seeking ABA therapy?
*
Please Select
Communication
Following Directions
Toileting
Challenging Behaviors
Independence Skills
Safety
Social Interactions
What is your #2 concern or goal in seeking ABA therapy?
*
Please Select
Communication
Following Directions
Toileting
Challenging Behaviors
Independence Skills
Safety
Social Interactions
How does your child mostly communicate?
Example: pointing, grabbing items, picture cards, grunting, one word, full sentences
Does your child exhibit developmental delays for their age?
Yes
No
Does your child engage in any of the following (please select all that apply)
Running away
Biting
Kicking
Hitting themselves
Hitting others
Touching unsafe items
Climbing
Putting things in their mouth
Preferred Therapy Location (please select one)
Clinic
Home
School
Community
Previous Therapies Attempted (please select all that apply):
Speech
Occupational Therapy
Physical Therapy
Feeding
Medication
Other
What is your availability for therapy? Please select all that apply:
Rows
Morning (8AM-11 AM)
Midday (11 AM-2 PM)
Afternoon (2 PM-5 PM)
Evening (5 PM-8 PM)
Monday
Tuesday
Wednesday
Thursday
Friday
Weekend
Back
Next
Insurance
** You must send us a copy of the front and back on insurance card in order to process**
Please upload an image of the front and back of insurance card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload supporting documents (diagnostic reports, evaluations, etc.)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: