Name of Primary Insurance Carrier for the client (if Private Pay - Enter Other). *
Choose
BlueCross BlueShield
Cigna / Evernorth
DMBA
EMI Health
HMHI / University of Utah
Medicaid
Select Health
Other
Please provide the full Primary Insurance ID number. (if Private Pay - Enter N/A)
Your answer
If the client has Secondary Insurance carrier, please provide the insurance carrier name.
Your answer
Please provide the full Secondary Insurance ID number.
Your answer
Does the client have an Autism diagnosis? *
Do you have a hard copy of the Autism diagnosis from the diagnosing physician? *
Please list any other diagnoses the client has.
Your answer
Select the primary method of communication for the client. *
Choose
Verbal
Gestural
Picture Cards
PECS
AAC
Other
What are your main concerns or areas that you feel the client needs help with? *
Your answer
What programs are you interested in for ABA? Check all that apply. *
Required
Does the client attend school? *
If yes, what grade, placement, and if not full day, what is their schedule? (if no - N/A) *
Your answer
Does the client have an IEP, 504, or BIP? Check all that apply.
Indicate any other services the client currently receives. Check all that apply. *
Required
Which days would the client be available for services? Check all that apply. (A minimum of 6 hours of services per week is required - actual hours required will be determined during assessment) *
Required
What times during those days would the client generally be available for services? Check all that apply. *
Required
Parent participation is essential to the the success of ABA therapy services. Are you willing to participate in the services and implement the treatment plans that our BCBA's create? *
How did you hear about Elevation Behavioral?
Anything else you would like to share with us about your child?
Your answer
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