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 number, you consent to receive 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 *

* It is your responsibility to ensure our providers are in network with your plan, if using insurance. We ONLY accept the insurance plans listed below for certain services (Unfortunately, we are NOT ABLE TO ACCEPT ANY MEDICAID plans); please visit our FAQ for more details!

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 plans only, ID # starts with W; we are not in network for 'Better Health'/ Medicaid plans)

FLORIDA BCBS (4 digit ID prefix ends in H; Behavioral Health managed by LUCET)

BCBS FEDERAL (ID prefix begins with R; Behavioral Health managed by LUCET)

ALL OTHER BCBS plans (NOT BCBS Federal/ Florida BCBS)

Cigna

Mayo/Medica

Are you seeking TESTING? (e.g., Gifted [IQ] testing, Diagnostic evaluations for Autism, ADHD, learning disorders, etc.) *

Please review our FAQ and ASSESSMENT webpages to better understand insurance requirements and limitations with testing services and the potential costs involved.

No

I am not sure

Yes - I will provide more details below about the testing I am seeking and/or diagnostic concerns

Are you seeking ABA THERAPY? *

*ABA is ONLY covered by insurance under the diagnosis of AUTISM- a copy of the diagnostic evaluation MUST be provided* Please review our FAQ and ABA webpages to better understand insurance requirements and exclusions related to ABA; contact your insurance company for details about your plan's policy for ABA coverage and cost.

No

I am not sure

Yes - my child has a DIAGNOSIS OF AUTISM and I understand my insurance plan's coverage and cost involved for ABA

Are you seeking COUNSELING/ THERAPY? *

Please review our FAQ and THERAPY webpages to better understand the types of therapy services we provide, including: individual counseling, family therapy, behavior therapy, parent training, CBT, PCIT, etc.

No

I am not sure

Yes - I will provide more details below about the type of therapy/counseling I am seeking and current presenting concerns

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.

My child is not receiving any other services 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., divorce proceedings, 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