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Referral Form

  • Thank you for making an inquiry about services with Achieving True Self! We look forward to the opportunity to support you and your family. Please complete this form to the best of your ability. A member of our team will reach out to you if we are able to accept your referral.

  • First Name: *
     Last Name: *

  • Gender:

  • Date of Birth:

  • Parent First Name:

  • Parent Last Name:

  • Parent DOB:

  • Address: *
    City: *
    County: *
    State: *
    ZIP: *

  • Phone:
    Contact Preference:

  • Are We Permitted to Contact You By Text Message?: *

  • What time of day may we contact you?:

  • Please List Languages Spoken at Home: *

  • How Were You Referred To ATS?:

  • Are you currently receiving any of the following services or funding? Please check all that apply:

  • Evaluation Month: *

  • Evaluation Year: *

  • Please mark the days and timeframes that your child is available to receive ABA treatment. We are a very intensive 1:1 service and prescriptions often involve a few hours a day and several days per week.

  • Days Available:

  • Times Available:

  • As specifically as possible, please list the timeframes of availability for morning, afternoon, and/or evening:

  • Please list any days or times of the day that your child is not available for treatment.

  • Limitations to Scheduling: *

  • Do you have any limitations or preferences with staffing (for example, male vs.female)?:

  • Do you have any pets?:

  • Does Your Child Have Any Allergies? Please List Below:

  • Insurance Type (please note if your plan is through Medicaid):

  • Insurance ID (and Group Number, if applicable):

  • Name and DOB of Policyholder (if commercial coverage):

  • Please upload the following as part of your referral request: a photo of the insurance card, a copy of the most recent evaluation or diagnostic report that documents the diagnosis and recommends ABA, and any other reports that would be helpful for us to review (an OT report, a speech evaluation, a school IEP, etc).

  • Documentation:
    (Acceptable Formats: .pdf)

* = Required

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