Name of Person Completing Form
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First Name
Last Name
Name of Individual Receiving Services*
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First Name
Last Name
Does your Childs name appear differently on his/her insurance card?
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Address
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Child's Primary Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Child's Date Of Birth
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MM
DD
YYYY
Child's Gender
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Child's Primary Language
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Does your child have siblings? If so, how many siblings?
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Are any of your children receiving or have received ABA therapy in the past?
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Primary Caregiver / Parent's Full Name
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First Name
Last Name
Primary Caregiver / Parent's Email
*
Primary Caregiver / Parent's Phone Number
*
Please enter a valid phone number.
(###)
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What is your preferred method of contact?
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Additional Caregiver / Parent's Full Name
First Name
Last Name
Additional Caregiver / Parent's Email
Additional Caregiver / Parent's Phone Number
Please enter a valid phone number.
(###)
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What is your preferred method of contact?
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What is your marital status?
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Legal Guardianship and Consent
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List who has legal authority to make medical decisions for this patient:*
Primary Healthcare Insurance
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Health Plan Member ID
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Policy Group Number
Policyholder's Name (Primary)
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DOB of Policyholder
*
Date
MM
DD
YYYY
If policyholder's address is different than child's primary address, please complete the following section. Otherwise continue with the next question.
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Do you have any additional insurance coverage for this child such as secondary Medicaid or coverage with a second parents' insurance?
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Primary Care Provider
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Primary Care Provider Phone Number
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Please enter a valid phone number.
(###)
###
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Hospital/ Clinic Name
Hospital/Clinic Fax Number
Please enter a valid phone number.
(###)
###
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Was your pregnancy full term?
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Were there any complications during pregnancy and/or delivery?
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Does your child have any medical or health conditions? If so, which?
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Is your child on medication? Is so, which?
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Does/did your child receive Early Intervention?
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(ASD) Diagnosis Report Document
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Has your child been diagnosed with Autism?
Please select the primary areas of concern you have regarding your child's ASD Diagnosis:
Please provide any additional information regarding your child that you feel will be helpful in coordinating services:
ABA Therapy
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Has your child previously received ABA Therapy?
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Is your child currently receiving ABA Therapy from another provider?
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Is your child currently on a waitlist for ABA Therapy?
Where would you like your child to receive ABA services? (Click all that apply)
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Caregiver collaboration is integral to facilitating your child's development. Do you agree to partake in caregiver/family training sessions at least once per month? (These sessions may be scheduled outside of regular therapy hours.)
Is your child in school?
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If selected public, does the child has an IEP or 504 Plan?
Which grade is your child in?
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What are your child’s hours at school?
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Does your child receive any supports at school?
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Has the school communicated concerns? If so, please detail their concerns below.
Is there a care coordinator at school that you communicate with?
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What is the contact information of care coordinator and do we have consent to communicate?
Date Of Diagnosis
Date
MM
DD
YYYY
I authorize Lumino ABA to contact me via text messages for communication purposes. I understand that standard text messaging rates may apply and that I can opt-out at any time by replying "STOP" or contacting LUMINO ABA directly.
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How did you hear about us
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Authorization
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I authorize Lumino ABA and its employees, agents and its representatives to furnish and/or release any information acquired in the course of my Behavioral Services and Telehealth services to insurance carriers concerning my diagnosed condition(s) and treatment (including information about substance abuse, mental health services, or HIV, if applicable) necessary to process my insurance claim(s), and to allow a photocopy of my signature to be used to process my insurance claim(s) for the lifetime of the claims. I authorize any holder of my patient health information to release to Lumino ABA and its agents and representatives any information needed to determine my insurance benefits and/or coverage. This authorization will remain in effect until revoked by me in writing.
This Form Was Complete by:
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Name
First Name
Last Name
Date of Form Completion:
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Date
MM
DD
YYYY
