Please thoroughly complete the patient profile. A clinical representative of the practice will get back to you shortly. If you become a client of ABSI, additional paperwork will be sent to you and need to be completed. Autism Behavioral Services strives to be able to provide services to all patients. However, we may not always be able to meet specific needs, or be equipped to perform therapeutic services for certain patient populations. Such patient populations may include, but not limited to patients who are medically complex. Please contact us for questions if your child has specific medical conditions that require additional equipment, or attention. Thank you.

    First Name*
    Last Name*
    Birth Date*
    Gender*
    Diagnoses*

    Parent / Guardian Information

    Parent / Guardian First Name*
    Parent / Guardian Last Name*
    Email Address*
    Cell Phone*
    Home Phone
    Work Phone
    Address*
    Address (Line 2)
    City*
    State*
    Zip Code*

    Insurance Information

    Insurance Provider*
    Policy Number*
    Group Number*
    Policy Holder First Name*
    Policy Holder Last Name*
    Policy Holder DOB*
    Services*
    Please describe your primary concerns*

    Emergency Information

    Emergency Contact*
    Contact Phone #*
    Relation to Client*
    Do we have permission to discuss important medical matters with this individual?*
    YesNo
    Allergies/Medical Alerts*

    Files & Documents

    Copy of Insurance Card
    Please provide a copy of the front and back of your insurance card
    IEP
    Applicable school documents
    Psychological Records
    Please include any psychological tests, results, diagnostic evals, reports, etc.
    Other
    Other applicable paperwork