New Patient Information

New Patient Information
Name of the Person Completing this form: *

First NameLast Name
Phone Number*
Email Address*
Legal Name of the Child: *

First NameLast Name
D.O.B.*
Child's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Diagnosis*
Date of diagnosis (if known)
INSURANCE INFORMATION: (please make sure to write in all of the information below)
Name of Insurance*
Member ID #*
Group #*
Secondary Insurance (Only if the child has a secondary insurance)
Member ID:
Emergency Contact (Parent or Legal Guardian) *

First NameLast Name
Is it ok to leave a voice message on your home or cell?*
ABCDIARIO BEHAVIORAL CONSULTING LLC and our staff CANNOT move forward in obtaining authorization for your child's ABA services unless this form and the following form are filled in completely.

On the Release of Information form please make sure to write in the Doctor's Name and contact information so we can contact your child's Doctor to obtain proof of diagnosis.

You may reach ABCDIARIO BEHAVIORAL CONSULTING LLC'S Office at 774-777-9472 You may reach ABCDIARIO BEHAVIORAL CONSULTING LLC's Director at 484-569-9866

Release to Obtain Information
Client Name
Child's legal name
DOB
This authorizes the release or ability to obtain protected health information concerning the above-named client. Health information may relate to my child's past, present or future physical or mental health condition, and the provision of my child's health care, or payment for my health care services. This information may be disclosed to or obtained from the following:
Agency Name/Contact Person
Doctor's Name and Practice
Address

Mailing Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
I understand that I may revoke this Authorization in writing at any time, however, I cannot revoke authorization for action that has already been taken. I further understand that I must provide any notice of revocation in writing to the Business Office at the address listed above. A copy of this release shall be valid as the original.

THIS CONSENT EXPIRES I YEAR FROM THE DATE SIGNED UNLESS OTHERWISE SPECIFIED.
Electronic or Handwritten Legal Guardian Signature

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Date

MonthDayYear
Date

Consent to Treatment
Child's Name
I, First Name Last Name (Parent/Legal Guardian) by signing below, consent to ABCDIARIO BEHAVIORAL CONSULTING for my child, whose name appears above.
I acknowledge that I will be part of the treatment team, and will participate in the development of the treatment plan. I understand that I will be receiving some or all of the services listed below and that at least some of them may be provided in my home.

X Initial Evaluation by a Board-Certified Behavior Analyst
X Assessment Process (Intake, FBA, Evaluation)
I have had the opportunity to express my ideas and opinions and to receive answers to my questions.
Signature

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