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Client Name
*
Client DOB
*
Client Gender
*
Male
Female
Non-binary
Other
Prefer not to say
Parent/Guardian Name
*
First and last name
Parent/Guardian phone number
*
Parent/Guardian email address
*
Address line 1
*
Address line 2
City
*
State
*
Arizona
California
Massachusetts
Minnesota
Texas
Utah
Virginia
Washington State
Other
Zip Code
*
Availability for in-home ABA sessions
*
Please include days of the week and specific times e.g. MWF 3-6 pm, TTh 2-5 pm, weekend availability
Referral source
*
Insurance
School
Current client
Doctor's office
Friend/Relative
Google search
Other
Funding source
*
Aetna
Anthem Blue Cross
Blue Cross Blue Shield of MA
Blue Shield of CA/Magellan
Cigna
Kaiser
Optum/United/Harvard-Pilgrim
TriCare
Tufts Health Plan
Tufts Health Together/Tufts Public Plan
Out of State Blue Cross
Other
Brief description of client needs
*
Are you currently receiving ABA services? If so, through what agency?
Does your child currently have an autism diagnosis?
*
Yes
No
In process
Does the child have a safety risk?
Yes
No
Please describe safety risk, if any:
Please upload a Diagnostic Assessment
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Primary Insurance Card or Military ID (front)
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Primary Insurance Care or Military ID (back)
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Secondary Insurance Card (front and back)
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