TLC Pre-Intake Form 2023

  • The Lovaas Center for Behavior Intervention Pre-Intake Form

  • Today's Date*
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  • PATIENT INFORMATION (Please use full legal name)

  • Date of Birth*
     - -
  • Gender*
  • Is the mailing address different from the physical address?*

  • *If there are multiple addresses, please let the office know

  • FUNDING INFORMATION

  • Policy Holder's Date of Birth*
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  • Format: (000) 000-0000.
  • Relationship to Patient:*
  • Format: (000) 000-0000.
  • Phone Type:*
  • Relationship to Patient:*
  • Format: (000) 000-0000.
  • Phone Type*
  • Who is the best contact?*
  • Preferred Method of Contact (check all that apply)*

  • Please provide us with a copy (front and back) of your child's insurance card and policyholder's ID below:

  • Do you have secondary insurance?*
  • Policy Holder's Date of Birth*
     / /
  • Relationship to Patient:*

  • Please provide us with a copy of your child's secondary insurance card and policyholder's ID below:

  • Do you have additional funding assistance? (e.g., ATAP, DRC)*
  • If yes, what type of funding assistance do you have? (check all that apply)*

  • MEDICAL DOCUMENTATION

  • Does your child have a medical autism diagnosis?*
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  • If your child does not have a medical autism diagnosis, we are unable to proceed with our intake. In order for your insurance to approve ABA therapy, a medical diagnosis is required. Please contact our office to get a list of diagnosing providers. We also recommend for you cntact your insurance and get a list of in-network diagnosing providers.

    Please submit this form so we can keep your contact information and follow-up with you.

  • SCHOOL & IEP DOCUMENTATION

  • Is your child currently enrolled in school?*
  • What placement is your child in? (check all that apply)*
  • Most current IEP* Date*
     / /
  • Annual IEP Date*
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  • Does your child have any history of disciplinary action? (e.g., suspension, detention)*
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  • Scheduling and Availability

  • The Lovaas Center ABA Plans & Availability

    Our organization offers two types of plans: Comprehensive and Focused. We currently offer in home therapy, in center therapy, or a hybrid model of both in home and in center therapy.

    Comprehensive plan consists of:

    • 25 to 40 hours a week of one-on-one therapy with an RBT
    • 20 to 32 hours of monthly supervision of the RBT
    • 4 to 6 hours of monthly parent training

    Focused plan consists of:

    • 15 to 24 hours a week of one-on-one therapy with an RBT
    • 10 to 20 hours of monthly supervision of the RBT
    • 4 to 6 hours of monthly parent training up to 1 year plan only

    Hours are based on your Behavioral Analyst recommendation and your child's needs. Please ensure you provide the most accurate availability for ABA services as our Scheduling Coordinator will prioritize the days and times requested on this form.

    *** We currently do not accept plans below 15 hours a week of one-on-one therapy***

  • I'm interested in:*

  • For center-only and hybrid models, the following scheduled are available:

    Children ages 18 months to 5.9:

    • 8:00 AM to 3:00 PM (Center Availability)
      • Currently unavailable

    Children ages 6 to 9:

    • 1:00 PM to 7:00 PM (Center Availability)
      • After-school availability may be limited

  • For home-only, the following schedule is available:

    • Sunday to Saturday
      • Morning availability

     

    ***After-school in-home is currently unavailable***

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  • I understand that the availability provided above is the most accurate for ABA services. I understand that any availability changes from the date of this form submission to the date of your full treatment authorization may result in discontinuing the intake process or delay the start of treatment.

  • Thank you for choosing us for your child's needs. Our Intake Coordinator will be contacting you within 24-48 business hours of receiving your request.

     

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