New Client Basic Information
Child's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Location
Cleveland
Columbus
Service Setting
In-center
In-home
In-home & In-center
In Child's Daycare
Not Sure
Contact Name
First Name
Last Name
Relationship of Contact to Child
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance
Please Select
Aetna
Anthem
Buckeye
CareSource
Cigna
Cleveland Clinic Plan (Aetna)
Medical Mutual
Molina
Other
Paramount
UMR
United Communnity Plan (Medicaid)
United (Commercial)
Name of Insurance Plan
Does the child already have an autism diagnosis?
Yes
No
Not Sure
If yes, what was the name of the facility and/or doctor who diagnosed them?
Does the child attend school? If so, what days and hours?
What days an times are you available for therapy?
Any other information you would like to share with us about your child
Submit
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