REFER A PATIENT

Please fill out the intake form below and submit the available supporting documentation.

Client Intake Form

Physician's Name

Practice Name

Phone Number

Fax Number

First Name

Last Name

Date of Birth

Age

Social Security Number

Recipient Number

Diagnosis

First Name

Last Name

Relationship

Phone

Home Address

Primary Insurance

Policy Holder

Please checkmark the documents submitted below. Required

Letter of Necessity

Diagnosis Assessment/Neurological Assessment

Individualized Educational Plan (I.E.P) / Early Steps Evaluation

Physician Assessment with behavioral intervention prescription code and diagnosis

Letter of Necessity

Upload supported file (Max 15MB)

Diagnosis/Neurological Assessment

Upload supported file (Max 15MB)

Individualized Educational Plan...

Upload supported file (Max 15MB)

Physician Assessment...

Upload supported file (Max 15MB)

Date

Initials

I declare that the information I've provided is accurate and complete.

Thank you for thinking of us for your patient's behavioral needs.

One of our team members will be in contact with the client's guardian to arrange a consultation.