Intake - ABA Programs

Welcome to A Brighter Avenue! We are happy you've chosen us to service your family. The following is a short list of general info followed by our intake form.

Please review the information below and complete and submit the forms online. If you have trouble completing this online version, please contact our Autism Early Learning Center Department at 480-612-0395 for a printed copy.

A Brighter Avenue services fall into four major categories:

Therapies - Speech, Occupational and Music

Autism Early Learning Center - Individualized, 1:1 programs for children with autism aged 2 - 6 in a clinic-based school setting

Applied Behavior Analysis - in home Early Childhood Autism Programs

Home and Community Based Services (HCBS) - Habilitation, Respite, and Attendant Care

Detailed service descriptions, links to request additional services, and contact information for all administrators and more can be found at www.abrighteravenue.com

Thank you and we look forward to working with your family!

Please press Next to continue with the Intake Form.

Developmental History

At what age did your child meet the following milestones:
Babble
Say first baby words
Put 2 words together
Use 3-4 word phrases
Roll over
Sit without support
Crawl
Walk
Wean from breastfeeding (if applicable)
Wean from bottle (if applicable)
Drink from open cup
Start baby food
Start finger foods
Eat using utensils
Potty Train

Attendance Policy
Child's Name

First NameLast Name
Parent/Guardian

First NameLast Name
Student Attendance Policy

Consistency is critical when it comes to your child’s progress.

Please take note of our attendance policies below:
- If your student will be absent, please give your teacher a 24 hour notice if possible. Please call the class phone: 480-612-0395.
- We realize there may be unexpected absences due to sudden sickness. To avoid spreading illness to our providers, and therefore other children, please be sure to keep your child home if your child has pink eye, any other contagious illness, and/or has had diarrhea or a fever off 100 degrees or higher or has vomited within the last 24 hours.
Please acknowledge
Signature

Privacy Practices

A Brighter Avenue is dedicated to maintaining the privacy of your health information. We are required to maintain the confidentiality of your health information and to provide you with this notice of our duties and methods concerning the privacy of your health information.
Use and Disclosure of your Health Information - We may be required to use or disclose your health information to the following entities and/or in the following circumstances:

To health oversight agencies as authorized by law. Situations may include inspections, audits, investigations, licensure, and disciplinary actions for example.

To public health authorities with proper authorization.

In response to a lawsuit or other court order or otherwise required to do so by law enforcement.

To federal officials for national security activities or intelligence as authorized by law.

When necessary to reduce/prevent a threat to your health/safety or the health/safety of someone else.

Your Rights Pertaining to Your Health Information - Client/Provider/Therapist files maintained by A Brighter Avenue are the physical property of A Brighter Avenue, however, you have the right to:

Request in writing that you be given the opportunity to view and/or copy items from your file.

Request in writing that information in your file be amended to correct any inaccuracies.

Request in writing a restriction on certain disclosures or uses of your health information.

Request in writing that communication of your health information be made via alternative means.

* Unless you submit an objection in writing, we may disclose to a relative or any other person identified in your file, your health information relevant to that person's involvement in your care or in the payment for your care or to notify such persons about your condition, location, death, or in the event of an emergency.
Consent
Signature

Pediatrician Information
Child's Name

First NameLast Name
Birth Date

MonthDayYear
Child's Diagnosis
Date of Diagnosis

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Doctor that diagnosed my child:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
Physician/Pediatrician Information

This information will be used to obtain a referral if needed.
Physician / Pediatrician

First NameLast Name
Physician / Pediatrician's Phone #

Area CodePhone Number
D.D.D. Information
Please select one
D.D.D. Support Coordinator, if applicable
Support Coordinator's Phone Number, if applicable

Area CodePhone Number

Private Insurance Information
Please select:
Private Insurance Company
Policy Number
Group Number
Insurance Co Customer Service #

Area CodePhone Number
Subscriber's Name

First NameLast Name
Subscriber's Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Claims Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Secondary Private Insurance Co if applicable
Policy Number
Group Number
Insurance Co Customer Service #

Area CodePhone Number
Subscriber's Name

First NameLast Name
Subscriber's Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Claims Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
AUTHORIZATION TO BILL INSURANCE - please select one

I hereby authorize the release of any medical or other information to A Brighter Avenue and consent to and authorize A Brighter Avenue to administer all treatments/services advisable by my physician and/or therapist. I authorize payment of benefits to A Brighter Avenue. If sent to me, I will give copies of EOBs and payments received from government and/or insurance companies to A Brighter Avenue, L.L.C. for services provided. (It is acceptable to endorse the back of the check and write "pay to the order of A Brighter Avenue" under the signature). I understand that I am responsible for any and all bills incurred and that any third party coverage or insurance is for the purpose of assisting me with my responsibility. I understand that if failure or refusal to pay results in collection and/or legal action, I am responsible for all collection and legal fees. I further understand that if/when A Brighter Avenue staff receives and relays to me a "quote of benefits" that this is not a guarantee of payment from my insurance company and that I have been advised that I should call my insurance company and verify my coverage. I understand that if services are rendered in conjunction with a DDD referral, then DDD is the secondary payer after insurance coverage.I understand that I may not currently have private insurance; however, if in the future DDD and/or myself notify A Brighter Avenue of an insurance change I hereby authorize the release of any medical or other information to A Brighter Avenue and consent to and authorize A Brighter Avenue to administer all treatments/services advisable by my physician and/or therapist. I authorize payment of benefits to A Brighter Avenue. If sent to me, I will give copies of EOBs and payments received from government and/or insurance companies to A Brighter Avenue, L.L.C. for services provided. (It is acceptable to endorse the back of the check and write "pay to the order of A Brighter Avenue" under the signature). I understand that I am responsible for any and all bills incurred and that any third party coverage or insurance is for the purpose of assisting me with my responsibility. I understand that if failure or refusal to pay results in collection and/or legal action, I am responsible for all collection and legal fees. I further understand that if/when A Brighter Avenue staff receives and relays to me a "quote of benefits" that this is not a guarantee of payment from my insurance company and that I have been advised that I should call my insurance company and verify my coverage. I understand that if services are rendered in conjunction with a DDD referral, then DDD is the secondary payer after insurance coverage.
Electronic Signature Consent

By checking here, you are consenting to the use of your electronic signature(s) in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature.
Signature
E-mail
example@example.com
Should be Empty:

Rows	Monday	Tuesday	Wednesday	Thursday	Friday
Mornings 8:00 - 11:30
Afternoon 11:30 - 3:30
Full Day 8:00 - 3:30

ABA Program Intake - Current Info

Developmental History

Developmental History

Attendance Policy

Privacy Practices

Consent for Treatment

Pediatrician Information

Physician/Pediatrician Information

D.D.D. Information

Private Insurance Information