Contact Information

Person Completing Form

Agency (if applicable)

Relationship to Individual

Phone

Fax Number

Name of individual to receive services

Date of Birth

Current Address

Gender

Diagnosis

Is There a Legal Guardian?Yes, there is a legal guardian.No, there is not a legal guardian.

Legal Guardian Name

Phone

Fax Number

Funding Source

Please check the funding source that applies.Community Living WaiverDAP FundingFamily & Individual Supports WaiverBuilding Independence WaiverMedicaid Managed Care OrganizationCommercial Insurance

Medicaid Number

Name of DAP Coordinator

Phone Number

Primary Insurance Provider

Type of Primary InsurancePrivateMedicaid

Medicaid / Policy Number

Policy Holder Name

DOB

Employer

Secondary Insurance Provider (if applicable)

Policy Holder Name

Policy Number

Please attach a copy of the front and back of your insurance card(s)

Service Needed

What service is needed?Applied Behavior AnalysisTherapeutic ConsultationOutpatient Therapy

Please Indicate any/all interfering behaviors or functional skill deficits that you hope to address through this service

School/Early Intervention

Program or School Name

Phone/Mobile

Fax

Current Education PlanIEP504Other

Diagnosing Provider

Practice Name

Physician

Address Line 1

Address Line 2

City

State

Zip Code

Phone/Mobile

Fax

Please attach psychological and/or other diagnostic report if applicable

Please note any ABA service preferences belowHome-basedClinic-basedNo Preference

Please indicate your availability for ABA sessionsWeekday MorningsWeekday AfternoonsWeekday Evenings

Referring Source Signature

First Name

Last Name

Date / Time

Please Indicate the Therapeutic Consultation Service Interested InBehaviorSpeechPsychologicalRecreation Therapy

Are you interested in participating in sessions remotely through telehealth?Yes, I am interested.No, I am not interested.

Residential Service Provider

Provider Name

Agency Name

Parent ProviderYes, the provider is a parent.No, the provider is not a parent.

Address Line 1

Address Line 2

City

State

Zip Code

Phone/Mobile

Group Home Provider

Agency Name

Address Line 1

Address Line 2

City

State

Zip Code

Phone/Mobile

Therapeutic Consultation Details

Support Coordinator

CSB

Phone Number

ISP Aligned Shared Outcomes that Therapeutic Consultation services can address

Shared Outcome #

Description of Outcome

Referring Source Signature

Date / Time

Please attach any documentation here

Get Started

Make a Referral

Referral Form

We look forward to learning more about your needs and connecting you with the right therapeutic options.

Get in Touch

We look forward to learning more about your needs and connecting you with the right therapeutic options.