Atlas Behavior Consulting: Referral & Insurance Form

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Atlas Behavior Consulting: Referral & Insurance Form

The following information must be completed and returned as a part of the intake process for
ABA services. These are required for billing and insurance authorization purposes. Any
incomplete sections will slow down the intake process and may cause delays in the start of
services.

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* Indicates required question

Email *

Your email

Patient Name *

Your answer

Patient Date of Birth *

MM

/

DD

/

YYYY

Patient School & Grade *

Your answer

Does the patient have an active IEP? *

Yes

No

What placement setting does the patient have at school? (Ex: Full/part time general education, self contained classroom, etc) *

Your answer

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