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Perspective Client Inquiry Form
Name of Person Completing Form
Date
/
Month
/
Day
Year
Date
State
Child's Full Name
First Name
Last Name
Demographic Information
Child's Primary Address
Child's Primary Address
Street Address Line 2
City, State, Zip Code
State / Province
Postal / Zip Code
Child's Date of Birth:
*
/
Month
/
Day
Year
Date
Child's Gender Identity:
Primary Caregiver / Parent's Full Name:
*
Primary Caregiver / Parent's Email
*
example@example.com
Primary Caregiver / Parent's Phone Number
*
Please enter a valid phone number.
Primary Caregiver/Parent's Preferred Gender Identity
Additional Caregiver/Parent's Name
Additional Caregiver/Parent's Email
example@example.com
Additional Caregiver / Parent's Phone Number:
Please enter a valid phone number.
Additional Caregiver/Parent's Preferred Gender Identity
Healthcare Information
Primary Healthcare Insurance
*
Health Plan Member ID
*
Policy Group Number
Policyholder's Name (Primary)
*
Policyholder's Date of Birth
*
-
Month
-
Day
Year
Date
Front Image of Insurance Card
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Back Image of Insurance Card
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If Policyholder's Address is different than child's primary address, please complete the following section. Otherwise move on to next question.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Insurance
Member ID for Secondary Insurance
Subscribers Name (Secondary)
Date of Birth of Secondary Policyholder
Secondary Insurance Card (Front & Back)
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Primary Care Provider Contact Information
Primary Care Provider
*
Hospital/ Clinic Name
Primary Care Provider Phone Number:
*
Please enter a valid phone number.
Health Clinic Fax Number:
Please enter a valid phone number.
Legal Guardianship and Consent
List which guardian or parent(s) have legal authority to make medical decisions for this child:
Mother
Father
Both
Other
ABA Services
Start Time of Availability
End Time of Availability
Notes (indicate restrictions to availability)
Monday
Tuesday
Wednesday
Thursday
Friday
Weekend
Family Guidance / Parent Training session per month, which may be scheduled outside of regular therapy hours. Do you understand and agree to attend these sessions?:
Yes
No
Is your child currently receiving services from another ABA provider:
Yes
No
If yes, Please provide the Name and Agency of ABA Provider
Please select the primary areas of concern you have regarding your child's ASD diagnosis:
Behavioral
Communication
Social Skills
Adaptive / Daily Living Skills
Other
Please provide any additional information that will help with establishing services for your child:
I understand that I can request a copy of this form in another language. I can reach out to ClientServices@discoveryaba.com.
Yes
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