Client Insurance Information

Client Insurance Information

Dear Future Team Dynamic Minds Family,

Thank you so much for reaching out and considering us as partners on your journey. We’re honored to walk alongside you as we explore the best ways to support your family with thoughtful, personalized care.

To begin, please submit the following:

☐ Copy of insurance card(s) – front and back
☐ Prescription for autism services or diagnostic report

☐ Any additional reports i.e IEP's, previous assessements, reports, etc. (optional)

All information shared will be kept confidential and handled with care, in full compliance with HIPAA guidelines.

If you have any questions while filling it out, feel free to reach out, we’re here to help.

With gratitude,
Kristine Mastronardi, M.S., BCBA, LBA
RDI® Certified Consultant
Owner, Team Dynamic Minds

📧 Email: krismastronardi@teamdynamicminds.com
📞 Phone: (908) 444-2745
🌐 Website: www.teamdynamicminds.com
Identifying Information
Legal name of child
Child's DOB

MonthDayYear
Date
Name of Person completing this form:
Child's Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email of Parent/Guardian

Insurance Information & Required Documents
Insurance Company Name
Member ID
Policy Holder’s Full Name
Policy /holders Date of Birth

MonthDayYear
Date
Relationship to Client
Upload Front of Primary Insurance Card

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Upload Back of Primary Insurance Card

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Upload Prescription for Autism Services or Diagnostic Report

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Upload any additional documents, reports, IEP's etc.

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Parent Guardian Signature

Thank you for taking the time to complete this form and sharing your insurance information. At Team Dynamic Minds, we use this information solely to determine coverage and eligibility for services.

Should you choose to move forward, we look forward to the possibility of building a partnership rooted in connection, curiosity, and joy.

Warmly,
The Team at Team Dynamic Minds
Guiding Minds. Nurturing Joy.
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