New Patient Enrollment

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 NameLast Name
Primary Parent or Guardian of Patient Phone
Please enter a valid phone number.
Primary Parent or Guardian Email
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Home Address - Location for home-based therapy*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health Insurance Provider*
Kaiser Permanente, Pacific Source, OHP, etc.
Patient Medical ID Card*

Please upload the from of the patient's medical ID
Cancelof
Patient Medical Record Number*
Patient Group Number*
Primary Care Physician*

First NameLast Name
Name of Diagnosing Professional*

First NameLast Name
Date of Autism Diagnosis*

MonthDayYear
Date
Current Behaviors or Deficits to Address:*

Physical AggressionMotor Skill DeficitVerbal AggressionCommunication DeficitRunning AwayAcademic ChallengesChallenges with TransitionUnsafe sexual behaviorHard time accepting "No".Social ChallengesImpulsive BehaviorInflexibilityExecutive Function ChallengesSensory OverwhelmSelf InjuryMeltdownsOther
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.*

	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.*

	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/Week5-10 Hours/Week10-15 Hours/Week15-20 Hours/Week20-30 Hours/Week30-40 Hours/Week
Should be Empty:

NEW Patient enrollment