NEW Patient enrollment
This information allows us to get authorization for services from your health insurance provider. Session availability and location information helps us prepare for services and match you with well suited providers in your area. This form is secure and HIPPA compliant. Personal health information is managed very carefully in order to protect our patient's information.
Name of Primary Parent or Guardian of Patient
First Name
Last Name
Relationship to the patient
Primary Parent or Guardian of Patient Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Parent or Guardian Email
Preferred form of contact (please check all that apply)
Phone calls - okay to leave a voicemail
Text messages
Email
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Please Select
Male
Female
Other
Home Address - Location for home-based therapy
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health Insurance Provider
*
Kaiser Permanente, Pacific Source, OHP, etc.
Patient Medical ID Card
*
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Please upload the from of the patient's medical ID
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Patient Medical Record Number
*
Patient Group Number
*
Primary Care Physician
*
First Name
Last Name
Please upload documentation of your child’s Autism Spectrum Disorder (ASD) diagnosis. Insurance requires proof of diagnosis before ABA services can begin. This documentation is typically a diagnostic report or evaluation from a qualified provider (e.g., psychologist, developmental pediatrician, neurologist).
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Name of Diagnosing Professional
*
First Name
Last Name
Date of Autism Diagnosis
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Behaviors or Deficits to Address:
*
Physical Aggression
Motor Skill Deficit
Verbal Aggression
Communication Deficit
Running Away
Academic Challenges
Challenges with Transition
Unsafe sexual behavior
Hard time accepting "No".
Social Challenges
Impulsive Behavior
Inflexibility
Executive Function Challenges
Sensory Overwhelm
Self Injury
Meltdowns
Other
Any additional information about behavior or skill deficits to address
*
General Availability for Direct Sessions with Patient. These sessions take place at the patient home and require a caregiver over 18 to be on the property. Please check any that you are interested in. We will work with you to identify exact session times. For example, if you are available for sessions 9AM-10:30 AM on Monday, you can click the 8-11 and 9-12 box.
*
Rows
8AM-10AM
10AM-12PM
12PM-2PM
2PM-4PM
4PM-6PM
6PM-8PM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
General Availability for Parent Training - Meetings with caregivers and the Behavior Analyst. The patient does not need to be present for this session and it can take place in person or via Telehealth call. Please mark any general availability and we will work with you to arrange exact meeting times.
*
Rows
8AM-10AM
10AM-12PM
12PM-2PM
2PM-4PM
4PM-6PM
6PM-8PM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
We will work with you to identify the medically appropriate amount of therapy per week. Please indicate below the amount of therapy you are interested in and available for at this time. Check all that apply.
2-5 Hours/Week
5-10 Hours/Week
10-15 Hours/Week
15-20 Hours/Week
20-30 Hours/Week
30-40 Hours/Week
How did you hear about our services? If someone referred you, please include their name and organization if known.
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