ABA Therapy Referral Form Download and Fill Out Form PATIENT INFORMATION Male Female (Gender assigned at birth) First Middle Last Street Address Apartment Number City State ZipDate of Birth MM slash DD slash YYYY Diagnosis (e.g. Autistic Disorder) Date of Diagnosis MM slash DD slash YYYY Patient’s Diagnosis Code (e.g. F84.0) Diagnosis Severity (per DSM-5 Diagnostic Criteria) Level 1: Requiring support Level 2: Requiring substantial support Level 3: Requiring very substantial support PRIMARY GUARDIAN INFORMATION Last First M.I. Street Address Apartment Number City State Zip Relationship to Client Primary Phone NumberEmail Address Date of Birth MM slash DD slash YYYY Employer Social Security Number Preferred Language PATIENT INSURANCE INFORMATION Primary Insurance Company Member ID Number Group Number Policyholder Name Policyholder Date of Birth MM slash DD slash YYYY Relationship to Patient Secondary Insurance Company Member ID Number Group Number State Funded Insurance? Yes No Name of State Fund State Plan ID Number PATIENT BEHAVIORPlease check any and all concerns that apply to the patient and please explain on the line below: Communication Verbal Aggression Self-injury Cognitive Skills Pre-verbal Physical Aggression Dangerous Behavior Community Participation Non-verbal Property Destruction Social Skills Play/Leisure Skills REFERRING PHYSICIAN INFORMATION Physician Printed Name Phone NumberFax NumberPhysician’s Signature Date MM slash DD slash YYYY HOW DID YOU HEAR ABOUT THRIVE ADVANCED CARE? Please check all that apply: Google Search Insurance Brochure Presentation Website Word-of-Mouth Event/Community Booth Mailer Mailer School District Physician Other Social Media EmailThis field is for validation purposes and should be left unchanged.
