Referral Process Questionnaire

Below is a list of questions to get some basic information from you. Once we have this information we can check with our analysts that provide services in your area to see if they have availability. Upon determining that there is an analyst with availability we will move forward, verifying eligibility with the payer source and obtaining any authorizations that might be needed.

After the initial paperwork is complete the analyst will contact you to set up an appointment to begin the Assessment. Services are provided in your home/community and sometimes at school if needed/appropriate. During the assessment, the analyst will determine what services will be needed on an ongoing basis, and will review that with you once the assessment is completed.

If you have any questions, please contact our administrator, Lisa.



Phone Number

How old is the person needing services?

 Male Female

What is their diagnosis?

 Are you looking for general ABA Therapy? Or are there behavior issues? Or both?’

If there are behavior issues, please list them.

What is your city?

What zip code do you live in?

What time of day would services need to be provided(e.g. after 3:00pm because of school, etc.)

Do you have insurance, Medicaid, MedWaiver or will this be private pay?

If you have insurance, what company?

If you have MedWaiver, have behavior services already been authorized?
 Yes No