Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

The name of the person completing this form *

First Name

Last Name

Are you the child's parent/do you have legal guardianship/power of attorney/custodianship of the child? *

PLEASE NOTE - Only the child's legal guardian/ parent may schedule an initial intake interview/ appointment. If parents are not married, the custody agreement MUST be provided at intake; all legal guardians must consent to services

Yes

No* (If no, do not proceed any further)

Phone Number *

By providing your phone number, you consent to receiving phone calls, voicemails, and text messages.

(###)

###

####

The number above: *

Is a cell phone and may receive text messages

Is a NOT a cell phone and cannot receive text messages

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please select which insurance you will be using (you MUST review our FAQ to ensure we accept your plan) *

*** We ONLY accept the insurance plans listed below for certain services. *** Unfortunately, we are NOT ABLE TO ACCEPT ANY MEDICAID plans (e.g., Aetna Better Health, United Medicaid, Humana Medicaid, Healthy Kids, CMS, Molina, Sunshine, CHIP, etc.)*

NONE - I will be paying out of pocket

Tricare PRIME - ACTIVE DUTY

Tricare PRIME - NON-ACTIVE DUTY

Tricare SELECT - ACTIVE DUTY

Tricare SELECT - NON-ACTIVE DUTY

Aetna (Commercial plan only; we are not in network for 'Better Health' plans)

FLORIDA BLUE (BCBS)

ALL OTHER BCBS (NOT Florida Blue)

Mayo/Medica

Cigna

Are you seeking a PSYCHOLOGICAL EVALUATION/ DIAGNOSTIC TESTING services? *

Before proceeding, please review the FAQ and ASSESSMENT pages of our website; it is VERY IMPORTANT that you understand insurance requirements and the potential costs involved with testing before scheduling this service.

No

I am not sure

Yes testing for AUTISM

Yes testing for GIFTED (*Insurance does NOT cover this service; SELF PAY ONLY)

Yes OTHER testing (provide explanation below)

Are you seeking ABA THERAPY? (An AUTISM diagnosis is requred) *

Before proceeding, please review the FAQ and ABA pages of our website

No

I am not sure

Maybe/ Eventually - my child does not have an Autism diagnosis and needs to be tested first

Yes - my child has been diagnosed with Autism (PLEASE PROVIDE DIAGNOSTIC REPORT) and I understand the type of coverage my insurance plan has for ABA

Are you seeking COUNSELING/ MENTAL HEALTH THERAPY/ INDIVIDUAL OR FAMILY THERAPY *

Before proceeding, please review the FAQ and THERAPY pages of our website

No

I am not sure

Yes

Is your child currently receiving services from other providers? If yes, please specify which. *

Please check ALL that apply. This information is necessary to prevent potential duplication of services and for continuation of care.

No other services are being provided at this time

ABA Therapy

Counseling/Mental Health Therapy

Psychological Testing

Psychiatric/ Medication Management Services

Speech/ Language Therapy, Occupational Therapy, &/or Physical Therapy

Services through the School System (IEP/ 504)

Other (describe below)

Does your child's case include potential involvement with the court or legal system? (e.g., child custody, DCF involvement, lawsuit, etc.)? *

We DO NOT provide services or documentation for any court or legal purposes!

Yes, my case currently does/ likely may have some court or legal aspect (describe below)

No, I attest that my case does not/will not involve any legal or court involvement