Autism Diagnosis Group Pediatric Form

1
Welcome to the Autism Diagnosis Group! Let's collect some information to get started.
2
Are you filling this out for an adult or a child/ individual you control healthcare decisions for?
Adult
Child/ Individual under your care
3
Do you have the legal authority/ power of attorney to make healthcare decisions for this individual/ child? * This field is required.
YESNO
4
Please have the individual who has legal authority to make healthcare decisions for this individual/ child complete the form. Thank you!
5
What's your name?* This field is required.
First Name
Last Name
6
What's your phone number?* This field is required.By providing your phone number, you consent to receive texts from Autism Diagnosis Group NJ PC and affiliates. Msg & data rates may apply.
Please enter a valid phone number
7
What's your email?* This field is required.
example@example.com
8
Would you like to use health insurance or pay out of pocket (we have payment plans!)?* This field is required.
Health Insurance
Out of Pocket (payment plans available!)
9
Which health insurance does the patient have?* This field is required.
Blue Cross Blue Shield
United Healthcare
Cigna
Aetna
OSCAR
Medicaid
Other
10
Is this a Medicaid plan?* This field is required.
YESNO
11
What is the child/ dependent's name?* This field is required.
First Name
Last Name
12
What is the child/ dependent's verbal level?
Minimally/Non-verbal - capable of a few words at most
Partially verbal/Phrase speech - ability to use phrases, but not complete sentences
Fully verbal - capable of complete sentences
13
What is the patient's date of birth?* This field is required.If you are under 18, please have a parent, guardian, or another adult fill out the pediatric form on www.adgcares.com.
Date
Month
Day
Year
14
What state is the patient located in?* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
15
Is the patient currently on a waitlist? If so, how long?* This field is required.
Not on a waitlist
Yes, 1-6 months
Yes, 6-12 months
Yes, 12-18 months
Yes, 18+ months
16
Book a free consultation with an ADG Care Concierge!* This field is required.The doctor's office will be calling from 210-446-9918 or 210-900-2599. Please add these numbers to your contacts.
17
The doctor's office will be calling from 210-900-2123 or 210-900-2599. Unrecognized numbers can sometimes be screened as spam so please add these numbers to your contacts. Please click "OK" below to continue!
OK
18
How did you hear about us?* This field is required.
Google Search
Facebook
Referral from a friend
Referral from a therapy center, doctor's office, etc.
Other
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Please provide the name of the clinic, therapy center, or doctor that referred you.
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Is there anything else you'd like to share? OPTIONAL
Should be Empty: