Outpatient Speech Referral Form

1. Client Information

First Name

Middle Name

Last Name

Birth Date

Gender:

Female

Male

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

2. Legal Guardian Information

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Name of Caregiver

First Name

Last Name

Same as legal guardian

Yes

No

Preferred Language

Address

Address Line 1

City

State

Zip Code

3. Referring Source Information

Referring Provider:

Agency/Role:

Phone/Mobile

Fax

Email

4. Reason for Referral

Please Indicate any/all interfering behaviors or functional skill deficits that you hope to address through this service:

5. School/Early Intervention

Program or School Name:

Agency or School Division:

Phone/Mobile

Fax

Current Education Plan

IEP

504

Other

6. Primary Care Provider

Practice Name:

Physician:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Fax

Medical Diagnosis of ASD?

Date of diagnosis:

Developmental Diagnostic Tool(s) Used

Vineland

ABA-S

Other

I don't know

Standardized Validated Tool(s) Used to Determine Medical Diagnosis of Autism:

ADOS

CARS

GILLIAM

Other

I don't know

Other Relevant medical and mental health diagnoses (if applicable):

ASD Diagnosing Provider Full Name (with credentials)

ASD Diagnosing Provider Agency:

Has a Letter of Medical Necessity for ABA services been completed by the PCP?

File Upload

Choose File

7. Insurance Eligibility Information

Primary Insurance Provider:

Primary Insurance Provider: Type of Primary Insurance:

Private

Medicaid

Policy Number

Policy Holder Name

DOB:

Employer

Secondary Insurance Provider (if applicable):

Policy Holder Name

Policy Number

Primary Insurance Provider: Type of Primary Insurance:

Private

Medicaid

10. Please attach a copy of the front and back of your insurance card(s)

Choose File

8. Other Supports or Services Utilized

Please indicate all supports or services that are currently being accessed or have been accessed in the past:

ABA Therapy

Therapeutic Consultation

Personal Assistance

Respite

Speech/Language Therapy

Occupational Therapy

Physical Therapy

Outpatient Counseling

Group Counseling

Companion Services

REACH

Group Day Services

Group Supported Employment

Individual and Family/Caregiver Training

Individual Supported Employment

In-Home Support Services

Workplace Assistance

Residential Services

9. Speech Service Preference

Please note any ABA service preferences below:

Home-based

Clinic-based

No Preference

Please indicate your availability for ABA sessions:

Weekday Mornings

Weekday Afternoons

Weekday Evenings

10. Availability for Sessions:

Please indicate all availability:

Morning

Afternoon

Evening

Referring Source Signature

First Name

Last Name

Date / Time

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