ASF New Client Intake

New Patient Intake
Current Status
Assessment Status
Treatment Status
Part I: Patient and Family Information
Service Area
Child's Name

First NameLast Name
Child's DOB

MonthDayYear
Date
Child's Sex
Is the Child currently attending School?
Does Child Have IEP?
Do You Have DSM-5 Check List?

Other
Is Your Child Currently Receiving other services (OT, PT, SLT)?
Please Specify which Services
School Name
If Yes, School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Language
Preferred Language
Caretaker/Guardian Filling out Form

First NameLast Name
Relationship to Child
E.g Mother,Uncle,Babysitter etc.
Caretaker Guardian Occupation
Child's Home Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Caretaker/Guardian's Cell Number

Area CodePhone Number
Caretaker/Guardian's Email
example@example.com
Part II: Diagnosing Information.

** To receive ABA services, you are required to have a referral/prescription for Applied Behavior Analysis with a diagnosis of Autism Spectrum Disorder AND a full evaluation done by a qualified specialist. You may upload this now or send it over to us later however we will be unable to move forward with your application until we have these documents.
Supporting Documents

Click here to upload
You may either upload now, or send it to us later, uploading now will greatly expedite the process (Acceptable formats are pdf, doc, docx ONLY) NO PICTURE FILES! Cancelof
Primary Insurance
If you do not see your insurance carrier It means we are currently unable to complete the intake process at this time. Sorry for the inconvenience.
Is this Medicaid?
Part III:Primary Insurance Information
Primary Member ID
Upload Primary Insurance Card (Front and Back)

Browse Files
jpg, jpeg, png, gif, pdf Cancelof
Part IV:Secondary Insurance Information

Only use this section if your child has 2 entirely independent insurance policies. DO NOT just submit your primary policy information again. Select "none" if this does not apply to your child
Secondary Insurance
If you do not see your insurance carrier It means we are currently unable to complete the intake process at this time. Sorry for the inconvenience.
Secondary Member ID
Upload Secondary Insurance Card (Front and Back)

Browse Files
jpg, jpeg, png, gif, pdf Cancelof
Additional Information
How did you hear about A Smiley Face
Name of Doctor

First NameLast Name
Comments/Additional Information
Administrative Use Only

Select "no" if you are a new patient
Are you A Smiley Face Administrator or Intake Coordinator
Access Code
ADMINISTRATIVE USE ONLY
Eligibility & Documents
Eligibility Status
Eligibility Checked

MonthDayYear
Date
Policy Details
Scanned Authorizations
Upload File(s)

Cancelof
Eligibility Reference # (if applicable)
Tour
Tour Appointment

MonthDayYear
DateHourMinutesAM/PM Option
Tour Location
Tour Supervisor
Tour Supervisor's Emails
Assessment
Date Requested

MonthDayYear
Date
Assessment Authorization #
Assessment Authorization Start Date

MonthDayYear
Date
Assessment Authorization End Date

MonthDayYear
Date

Assessment Authorization Received By
Assessment Appointment

MonthDayYear
DateHourMinutesAM/PM Option
Assessment Location
Where will assessment take place
Assessment Supervisor
Who will perform the assessment
Assessment Supervisor Email
example@example.com
Reminder
Treatment
Date Requested

MonthDayYear
Date
Treatment Authorization #
Treatment Authorization Start Date

MonthDayYear
Date
Treatment Authorization End Date

MonthDayYear
Date

Authorized Provider
If "Other" Please specify
Treatment Authorization Received By
Reply To All
example@example.com
Update
Treatment Supervisor
Who will be the BCBA on the case
Treatment Start Date

MonthDayYear
Date
Schedule
Updates

If there are any updates to ANY of the following, please update the box below.
Has any of the following been updated?
If no, click "NO"
Discharge/Discontinued Date

MonthDayYear
Date
Should be Empty:

Rows	Code	Units
Line 1
Line 1

Rows	Code	Units
Line 1
Line 2
Line 3
Line 4
Line 5
Line 6
Line 7

New Patient Intake

Current Status

Part I: Patient and Family Information

Part II: Diagnosing Information.

Part III:Primary Insurance Information

Part IV:Secondary Insurance Information

Additional Information

Administrative Use Only

Eligibility & Documents

Scanned Authorizations

Tour

Assessment

Treatment

Updates