Student Name

Date of Birth

Gender
MaleFemaleOther

Students address

Street Address Line 2

City

State/Province

Postal / Zip Code

Does student have a medical ASD diagnosis?

Responsible Caregiver Name

Phone Number

Email

#2 Responsible Caregiver Name

#2 Caregiver Phone Number

Name of Prescribing Physician

Dr. Phone Number

Hours available for ABA services (*10 hour minimum required)
MorningAfternoon (11-3)4PM-7PMAfter 7PMWeekend flexibleOther

Days Requesting Services (*4 days a week required)
MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Referred by (allow us to thank them)
[radio* referred-by use_label_element default:1 "Physician" "Google/Internet Search" "Friend" "Esti/ Intake Coordinator" "Other"]

Preferred method of contact

Additional comments that you feel we should know

Please provide us with any relevant information that you may feel is important

Insurance Information

please provide us with primary and secondary insurance information (almost done)

Primary person Policyholder

Relationship to Student
[radio* RelationshiptoStudent use_label_element default:1 "Mother" "Father" "Self" "Otehr"]

Policyholder DOB

#1 Primary Insurance Provider

OTHER insurance if not listed above

Group Number primary

Insurance Phone Number

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#2 Insurance Provider

#2 Insurance ID number

#2 Insurance Phone Number

Snap or upload photo of front of insurance card

Snap or upload photo of back of insurance card

Consent Signature

Thank you for your application we will contact you within the next 24 hours.

b>IMPORTANT: Before we can verify your coverage with your insurance company, we need a copy of the front and back of your insurance card. Please scan or snap a picture of both sides and submit them here or email info@ahappyfam.com If you require assistance, please call us at 818-330-5328 or email us.

A quote of benefits and/or authorization does not guarantee payment. Payment of benefits is subject to all terms, conditions, limitations, and exclusions of the member's contract at the time of service**you will always be solely responsible for letting your provider know about changes in insurance and/or payment status of services. Any services not fully. covered by insurance will be the responsibility of the patient/ family, caregiver

Privacy Disclaimer Achievement Behavior will never sell your information to any third-party person we are committed to protecting your personal information and your right to privacy, please contact us at info@ahappyfam.com if you have any questions

Privacy guarantee: We do not share your information and will contact you only as needed to provide our ABA service.