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👋 Hi! I'm here to help you learn about our ABA services. Ask me anything about:
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Scheduling an intake
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What services do you offer?
How do I schedule intake?
Where are you located?
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About
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Intake
Staff
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Schedule Client Intake
Complete the intake form below and submit your information.
Patient’s Information
First Name
Last Name
Address
City
State
Zip
Date of Birth
Sex
Select
Female
Male
Other
Prefer not to say
Primary Guardian Information
First Name
Last Name
Relationship to Patient
Address
City
State
Zip
Phone Number
Email
Insurance Information
Primary Insurance Company
Type of Plan
Policy ID #
Phone Number
Secondary Insurance Company
Type of Plan
Policy ID #
Phone Number
Secondary Guardian Information
First Name
Last Name
Relationship to Patient
Address
City
State
Zip
Phone Number
Email
Emergency Contact
Name
Relationship to Patient
Phone Number
Additional Background Information
Race
Ethnicity
Preferred Language
Interpreter Needed
Select
Yes
No
Spiritual + Cultural Values
Other Treating Providers (other services the child receives)
Relevant Family Values (ex: adopted, DCF, etc)
Documents Needed
Front & Back of Insurance Card
Physical
Diagnosis of Autism (Evaluation)
Upload Documents
Upload Insurance Card
Upload Autism Evaluation
Upload Physical Exam
Electronic Signature
I confirm the information provided is accurate.
Signature (initials)
Date
Submit Intake Request
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