Child's Full Name

Date of birth

Diagnosis (if applicable):

Primary Language Spoken at Home:

School/Daycare (if applicable):

Parent/Guardian Name:

Relationship to the Child

Phone *

Email *

Parent/Guardian 2 Name:

What's Your Relationship to the Child?

Your Phone Number:

Email:

Home Address:

Preferred Contact Method

Phone
Email
Text/SMS

Insurance Information

Primary Insurance Provider:

Member ID:

Group #:

Policy Holder Name:

Policy Holder Date of Birth:

Relationship to Client:

Secondary Insurance (if any):

Upload Front Copy of Insurance Card(s)- Official Diagnosis From a Qualified Provider- Physician Referral (if required by your insurance)

Upload or attach copies of: - Back copy of insurance card(s)- Official diagnosis from a qualified provider- Physician referral (if required by your insurance)

Upload a copy of the letter stating your childs autism diagnosis which is required by your insurance.

Emergency Contact Name & Medical Info

Emergency Contact Name (other than parent):

Emergency Contact Phone Number:

Relationship to Client:

Allergies

Food
Medication
Others

Medical Conditions:

Medications

Primary Care Physician Name & Contact Info:

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