POSS ABA INTAKE FORM-Updated

Intake Questionnaire ABA Therapy

-CONFIDENTIAL-
Please complete this Intake Form regarding your child. Progressive Option Support Services views all the information that you provide us with as strictly confidential on this HIPAA compliant submission platform. This information is helpful for us in developing an initial understanding of your child’s needs and provides critical information for us to discuss with your insurance company to get authorization for services.

Please upload front and back copies of your insurance card, a copy of the autism evaluation report, and/or a copy of the doctor’s script with ASD diagnosis.

A MEMBER OF OUR STAFF WILL CONTACT YOU WITHIN 24HRS
Today's Date
How did you hear of our practice?*

Search EngineSocial MediaWord of MouthInsurance CompanyOther
General Information
Name (of person completing this form)*

First NameLast Name
Relationship to Child/Adolescent:*
Legal Name of Child/Adolescent*

First NameLast Name
Child/Adolescent's Date of Birth:*

MonthDayYear
Date
Child/Adolescent Age:*
Ex: 5 years old
Parent/Guardian Name*

First NameLast Name
Parent/Guardian 2 Name

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Email*
example@example.com
Home Phone Number*

Area CodePhone Number
Alternative Phone Number

Area CodePhone Number
Parent/Guardian (Employer Name):*
Parent/Guardian (Employer Address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian (Employer Phone #):*

Area CodePhone Number
Availability for Service Delivery*
Days & Times - (ex Mon-Frid. 3-5pm; Sun after 4pm)
Have you received ABA therapy with another Company within the last 6 months?*

YesNo
Insurance Information
Name of Policy Holder:*
Policy Holder Date of Birth:*

MonthDayYear
Date
Name of Insurance:*
Horizon, Aetna, United Health Care
Insurance Phone Number*

Area CodePhone Number
Member ID Number:*
Group ID Number:*
Front of Insurance Card*

Browse Files

Cancelof
Back of Insurance Card*

Browse Files

Cancelof
FULL Report with ASD Diagnosis/ Doctor's Script with ASD Diagnosis

Browse Files

Cancelof
Additional Uploads

Browse Files
Ex: IEP or 504 Plan Cancelof
Additional Uploads

Browse Files
Ex: Speech Evaluation, Social Assessment, OT Evaluation, etc Cancelof
UUID
Please remember to upload front and back copies of your insurance card, a copy of the autism evaluation report and/or a copy of the doctor’s script with the ASD diagnosis.
Should be Empty:

Intake Questionnaire ABA Therapy

General Information

Insurance Information