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Elevate Contact Form

www.ElevateSeattle.net
Your Name*

First NameLast Name
Your preferred Contact Method*

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Your Phone Number
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Your Email
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Child's Name
Child's Age*
Child's School
IMPORTANT NOTE: OUR SERVICES & PROGRAMS ARE AVAILABLE IN BELLEVUE & SEATTLE, WA AREAS TO AUTISTIC COMMUNITY

We offer ABA services in clinic, school, home, community & more! We also offer our community & center based After-School Social Groups (click here to learn more) & All-Day Summer Social Program (click here to learn more.)
Which Elevate Services and/or Programs are you interested in?*

Applied Behavior Analysis (ABA)Intensive ABA After-School Social GroupsSummer Intensive ABA Social ProgramI am interested in All of the Above Services & Programs!
Comments and/or Questions for Elevate Team:
Child's Insurance Information

IMPORTANT NOTE: WE ARE CURRENTLY IN-NETWORK FOR PREMERA, REGENCE, FIRST CHOICE HEALTH & ANY BLUE CROSS INSURANCE
Insurance Company
Insurance Company/Payer*

PremeraRegenceFirstChoiceHealthMy Insurance Carrier is NOT listed above so I would be an Out-Of-Network Client, and I understand that Elevate will NOT directly bill my Out-Of-Network Insurance Plan -- I will be responsible for paying for session prior to session start then can submit the Invoice/Receipt to my insurance carrier directly if I would like to request reimbursement from my insurance carrier.My Insurance Carrier is NOT listed above so I would be an Out-Of-Network Client, though I do not intend to use insurance or a school district payer so I plan to be paying in full out of pocketNone of these options
Please Upload Front of Insurance Card (Image will suffice)

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Please Upload Back of Insurance Card (Image will suffice)

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Is Child covered by multiple health insurance policies?*

YesNo, Child is NOT Covered by Multiple Health Insurance Policies
If Child Is covered by Multiple health insurance policies, please indicate the secondary insurance company below.
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Elevate Contact Form

Child's Insurance Information