CHIVALRY ABA THERAPY INTAKE FORM

CHIVALRY ABA INTAKE FORM

We’re here to support your family every step of the way. Please complete the form below, and our team will review your information, verify your insurance, and contact you shortly to get services started.
Parent / Guardian Full Name

First NameMiddle NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Child full name

First NameMiddle NameLast Name
Date of birth

MonthDayYear
Date
Gender
Primary address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary language spoken
Does the child have an autism diagnosis?
Diagnosing provider name
Diagnosis date

MonthDayYear
Date
Diagnostic evaluation (PDF)

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Primary Insurance Provider
Member ID
Group Number
Policy Holder Name

First NameMiddle NameLast Name
Policy Holder Date of Birth

MonthDayYear
Date
Relationship to Child
Upload Front of Insurance Card

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Upload Back of Insurance Card

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Do you have secondary insurance?
Insurance company name
Policy type
Member ID
Group number
Policy holder full name

First NameMiddle NameLast Name
Policy holder date of birth

MonthDayYear
Date
Upload secondary insurance card

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Pediatrician Name

First NameLast Name
Pediatrician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Do you have a referral for ABA therapy?
Upload Referral Document (if available)

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Services Interested In
Preferred Start Timeframe
Days Available
Primary concerns

Other
How did you hear about us?

Other
HIPAA Acknowledgment
Consent to Contact
Authorization to Verify Insurance Benefits
E-Signature
Date

MonthDayYear
Date
Should be Empty:

CHIVALRY ABA INTAKE FORM