Page 1 of 3

All fields marked with * are required.

*Name of Parent/Guardian

*Parent/Guardian Phone Number

*Parent/Guardian Email Address

*Child's First Name

*Child's Last Name

Child's Middle Name or Initial

*Child's Gender
Male
Female

*Date of Birth :

*Address

*City

*State

*Zip code

*Services you are interested in:
ABA Therapy
Behavior Intervention Plan
Intensive Toilet Training
Social Skills Training
Assesment/Program Development
Communication Skills
Parent Training
School Facilitation
Social Skills
Other

*Please indicate other services you are interested in:

*Please tell us a little about your child.
Please provide more details about your child.

*What are your expectations for treatment?

*How did you find us?

*Place an X on each day/time you are available.

Monday

Tuesday

Wednesday

Thursday

Friday

09:00AM

Monday

Tuesday

Wednesday

Thursday

Friday

10:00AM

Monday

Tuesday

Wednesday

Thursday

Friday

11:00AM

Monday

Tuesday

Wednesday

Thursday

Friday

12:00PM

Monday

Tuesday

Wednesday

Thursday

Friday

01:00PM

Monday

Tuesday

Wednesday

Thursday

Friday

02:00PM

Monday

Tuesday

Wednesday

Thursday

Friday

03:00PM

Monday

Tuesday

Wednesday

Thursday

Friday

04:00PM

Monday

Tuesday

Wednesday

Thursday

Friday

05:00PM

Monday

Tuesday

Wednesday

Thursday

Friday

06:00PM

Monday

Tuesday

Wednesday

Thursday

Friday

*Date Completed :

Page 2 of 3

All fields marked with * are required.

*Does your child have a diagnosis of autism?

Diagnosing Medical Profession Information:

*Name

*Address

*City

*State

*Zip code

*Please upload your diagnosis report.

Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file.

*Do you allow us to contact the psychologist/physician?
Yes
No

I certify that I am the parent or legal guardian with responsibility for health care decisions of for the child listed above.

*Signature

Please sign in the box below using your mouse, touch screen, or touchpad.

CLEAR

I accept that this is the legal representation of my signature.

In many cases insurance will not cover therapy without a diagnosis of autism. Feel free to continue filling out the application we can check with your insurance but in most cases this would mean services would be out of pocket.

*Has your child ever received a psychological exam?

Diagnosing Medical Profession Information:

*Name

*Address

*City

*State

*Zip code

*Please upload the psychological exam.

Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file.

*Do you allow us to contact the psychologist/physician?
Yes
No

I certify that I am the parent or legal guardian with responsibility for health care decisions of for the child listed above.

*Signature

Please sign in the box below using your mouse, touch screen, or touchpad.

CLEAR

I accept that this is the legal representation of my signature.

Page 3 of 3

All fields marked with * are required.

Primary Medical Insurance Company

Member ID or Policy Number

Group Number

Policy Holder Name

Policy Holder DOB

Additional Information

If the policy belongs to another patient, specify the relationship here. Or, specify any other relevant information.

Second Insurance Company

Member ID or Policy Number

Group Number

Policy Holder DOB

Additional Information

If the policy belongs to another patient, specify the relationship here. Or, specify any other relevant information.

Please upload the front and back of your insurance card

Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file.

Please upload your diagnosis report if you have one

Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file.

Please upload your Diagnostic evaluation/report (completed by a doctorate level clinician,Diagnosis date and by whom)

Please click "choose file" to select a file. After selecting the file, click the upload button to upload them. Click the X to delete a file.

Please upload your MD prescription or signed coordination of care letter within the last 6 months

Please click "choose file" to select a file. After selecting the file, click the upload button to upload them. Click the X to delete a file.

[NOTE: Ordering physician information such as address, name, tax ID and phone number.]

Please upload any reports such as IEP, Speech, or ABA that you may have.

Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file.

Age of the first ABA treatment

1. Please upload your Diagnostic evaluation/report (Autism Diagnostic Observation Schedule – Second Edition (ADOS-2), Autism Diagnostic Interview – Revised (ADI-R), the Diagnostic Interview for Social and Communication Disorders (DISCO), and/or other known evidence-based tools. The diagnosis must be made by a practitioner enabled by the OCGA practice acts to diagnose behavioral health/ intellectual/developmental conditions. An initial diagnosis should include the following-nConducted within the past three (3) years. • Minimum of two (2) assessment tools (1 clinician observational assessment, 1 caregiver assessment). • Summary of each individual assessment. • Include the date it was completed and include the tests administered with scores. • Include the evaluators name and credentials. A diagnostic re-evaluation to re-confirm diagnosis is required, at a minimum, every three (3) years and must be completed by a licensed professional. The re-evaluation must include, at a minimum, 1 clinician observational assessment. Children who are three (3) years of age or younger when they receive an initial diagnostic assessment, should be re-evaluated in one (1) to two (2) years. School psychoeducational assessments are not acceptable for diagnostic evaluations.)

Please click "choose file" to select a file. After selecting the file, click the upload button to upload them. Click the X to delete a file.

2. Letter of Medical Necessity ( This can be completed by the diagnosis physician or child's pediatrician and must be dated within the last 6 months)

Please click "choose file" to select a file. After selecting the file, click the upload button to upload them. Click the X to delete a file.

3. Copy of the Medicaid card and/or Medicaid

Please click "choose file" to select a file. After selecting the file, click the upload button to upload them. Click the X to delete a file.

4. Individualized Family Service Plan (if applicable).

Please click "choose file" to select a file. After selecting the file, click the upload button to upload them. Click the X to delete a file.

5. Individual Education Plan or IEP

Please click "choose file" to select a file. After selecting the file, click the upload button to upload them. Click the X to delete a file.