Get in Touch

Our staff will schedule an appointment to meet you and to learn about the referral’s needs and desires for placement. Get in touch with us today!

Contact Form
ABA Referral Form
TC Referral Form
Outpatient Speech Referral Form
Locations

Contact Form

TC Contact Form

First Name

Last Name

Contact Number

Your Message

Date

ABA 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

Guardian Email

Phone/Mobile

Name of Caregiver

First Name

Last Name

Same as legal guardian

Yes

Preferred Language

Address

Address Line 1

City

State

Zip Code

3. Referring Source Information

Referring Provider:

Agency/Role:

Phone/Mobile

Fax

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

7. Autism Spectrum Disorder and Other Diagnoses

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?

8. Please attach psychological and/or other diagnostic report if applicable

File Upload

Choose File

9. Insurance Eligibility Information

Primary Insurance Provider:

Primary Insurance Provider: Type of Primary Insurance:

Private

Medicaid

Medicaid or Policy Number

Policy Holder Name

DOB:

Employer

Secondary Insurance Provider (if applicable):

Policy Holder Name

Policy Number

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

Choose File

11. 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

12. ABA 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

13. Availability for Sessions:

Please indicate all availability:

Morning

Afternoon

Evening

Referring Source Signature

First Name

Last Name

Date / Time

TC Referral Form

Therapeutic Consultation Service Referral Form

1. Please Indicate the Therapeutic Consultation Service Interested In:

Behavior

Speech

Psychological

Recreation Therapy

Are you interested in participating in sessions remotely through telehealth?

Yes

2. Individual Being Referred for Services

First Name

Last Name

Date Of Birth

SSN

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Guardian:

Phone/Mobile

Guardian Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Relationship:

Primary Language of Individual

Primary Language of Legal Guardian

3. Individual Making Referral

Individual Making Referral

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Relation to Individual:

Parent

Grandparent

Legal Guardian

Family Member

Non Family Member

Support Coordinator

Program Manager

Educator

REACH

Other Provider

4. Residential Service Provider (If Applicable)

Service Provider (Agency/Name)

Parent Provider?

Yes

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

5. Service Funding Source and Services Requested: Waiver

Medicaid Number:

Requested Services

Therapeutic Behavior Consultation (Medicaid Waiver - FIS and CL only)

Behavior Consultation (Alternate funding source)

Support Coordinator

CSB

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

ISP DATES

PCR Date 1st

PCR Date 2nd

PCR Date 3rd

PCR Date 4th

6. Diagnoses and Other Services

Diagnosis (please select all that apply)

F84.0: Autism

F70: Mild Intellectual Disability

F71: Moderate Intellectual Disability

F72: Severe Intellectual Disability

F73: Profound Intellectual Disability

F79: Unspecified Intellectual Disability

Other Diagnoses

Other Treatments and Services Currently Being Utilized (Check all that apply)

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

Inhome Support Services

Workplace Assistance

Residential Services

Other Diagnoses

7. ISP Aligned Shared Outcomes that Therapeutic Consultation services can address.

Shared Outcome #

Description of Outcome

Shared Outcome #

Description of Outcome

Shared Outcome #

Description of Outcome

Behavioral

8. Describe the Interfering Behaviors (if applicable)

Interfering Behavior(s)

Describe the interfering behavior(s)

Where does the behavior typically occur?

When does the behavior typically occur?

Severity

Frequency

Interfering Behavior(s)

Describe the interfering behavior(s)

Where does the behavior typically occur?

When does the behavior typically occur?

Severity

Frequency

Interfering Behavior(s)

Describe the interfering behavior(s)

Where does the behavior typically occur?

When does the behavior typically occur?

Severity

Frequency

Interfering Behavior(s)

Describe the interfering behavior(s)

Where does the behavior typically occur?

When does the behavior typically occur?

Severity

Frequency

Speech/Language

9. Please Indicate and Describe Communication Concerns

Communication Concern

Non-verbal or limited functional communication and pragmatic language

nintelligible or echolalic speech

Impairment in receptive

Where is your primary care doctor located ?

Phone Number of primary care doctor:

Psychological

10. Please Describe Psychological Symptoms and/or Concerns

Recreation Therapy

11. Please List domains/areas you feel recreation therapy may benefit this individual:

Yes

Please list current recreational activities the individual participates in or has interest in participating in in the future:

Other

13. Other Information:

14. Preferred Items, Activities, and Environments:

Aversive Items, Activities, and Environments:

15. Current Residential, Educational, Mental Health, Skill Building, Community Engagement, Leisure, and Job Related Services

Service

Phone/Mobile

Organization Name

Address

Contact Name

16. Current Medications - may also attach as document to the end of this referral form.

Name

Purpose

Dosage

Name

Purpose

Dosage

Name

Purpose

Dosage

17. Current Schedule

Dropdown

Monday

Tuesday

Wednesday

Thursday

Dropdown

Friday

Saturday

Sunday

Referring Source Signature

First Name

Last Name

Date / Time

Clinician- No other signatures required but please ensure that all stakeholders are aware of the referral, requirements, and have had all questions answered prior to submitting authorization requests.

Date of Initial Staff Contact with Referring Source

Please attach any documentation here:

Choose File

Date of Initial Staff Contact with Referring Source

Reason for Referral:

Results of Initial Contact:

Intake for Services

Placed on Waitlist

Referred Out to Other Provider(s)

If Referred to Other Provider(s), Please List Those Provider(s) Here:

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

Preferred Language

Address

Address Line 1

City

State

Zip Code

3. Referring Source Information

Referring Provider:

Agency/Role:

Phone/Mobile

Fax

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

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

WALL RESIDENCES MAIN OFFICE

122 Eco Village Trail
Floyd, VA 24091

SALEM

405 Yorkshire Street
Salem, VA 24153

CHRISTIANSBURG

8 Radford Street
Christiansburg, VA 24073

Suites 102B and 201A

Respect. Autonomy. Assent. Dignity.

We provide socially valid, evidence based outpatient therapies by highly qualified clinicians.

Accessibility Statement

Contact Us

P.O. Box 235
Floyd, Virginia 24091 540-745-4216 info@walltherapeuticsolutions.com

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