ABA Therapy Referral Form Download and Fill Out Form CommentsThis field is for validation purposes and should be left unchanged.PATIENT INFORMATION Male Female (Gender assigned at birth) FirstMiddleLastStreet AddressApartment NumberCityStateZipDate 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 LastFirstM.I.Street AddressApartment NumberCityStateZipRelationship to ClientPrimary Phone NumberEmail Address Date of Birth MM slash DD slash YYYY EmployerSocial Security NumberPreferred LanguagePATIENT INSURANCE INFORMATION Primary Insurance CompanyMember ID NumberGroup NumberPolicyholder NamePolicyholder Date of Birth MM slash DD slash YYYY Relationship to PatientSecondary Insurance CompanyMember ID NumberGroup NumberState Funded Insurance? Yes No Name of State FundState Plan ID NumberPATIENT 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 NamePhone NumberFax NumberPhysician’s SignatureDate 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
