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Request Services for Your Child
Fill out a request for services form

May 16, 2011

To explore possible enrollment in any of our ABA programs, complete the Request for Services form and submit it to our office. This allows our clinical staff to quickly gather information about your child so we can efficiently answer your questions and give you a recommendation on which services should be provided to meet your child’s individualized needs.

Please fill out this form in its entirety. Upon receipt of your completed form, we will contact you within one to two weeks to further discuss our services and program philosophy.

Autism Partnership
200 Marina Drive
Seal Beach, Ca 90740

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(562) 431-9293

Fax (562) 431-8386

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We're interested in services at the following location(s): *

Tell us about your family

Child's Full Name: *

Date of Birth: *

Current Age: * years old

Home Street Address: *

Home City: *

Home State: *

Home Zip Code: *

Parent's Name: *

Parent's Home Number: *

Parent's Cell: *

Parent's Email: *

Parent's Date of Birth: *

Parent's Name: *

Parent's Home Number: *

Parent's Cell: *

Parent's Email: *

Parent's Date of Birth: *

Service information

Has your child received a diagnostic evaluation? : *

If yes, who performed the evaluation?:

When was the evaluation performed?:

Who referred you to Autism Partnership?: *

What services are you seeking?: *

Individual Treatment

Social Skills Group

Functional Behavioral Assessments

Unsure

Primary Insurance information

Name of Primary Insurance Company: *

Subscriber's Name for Primary Insurance: *

Subscriber's Relationship to Child: *

Have services been authorized?: *

Indicate the specific services that have been authorized: :

Secondary Insurance information

Name of Secondary Insurance Company: *

If none, type “n/a”

Subscriber's Name for Secondary Insurance:

Subscriber's Relationship to Child:

Have services been authorized?:

Indicate the specific services that have been authorized: :

Current Services that are being Provided

ABA at home or school, Speech, OT, etc.

Are services currently being provided?: *

Service:

Provider:

Frequency:

School Information

School District:

IEP/IPP was held on:

Does your child attend school?: *

School Name:

Type of Classroom:

School Phone:

Grade Level:

Indicate Days Child Attends School:

School Start Time:

School End Time:

Additional information

What treatments have you tried?: *

What are the goals for your child?: *

Questions, Concerns or Special Circumstances: *

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Request Services for Your Child Fill out a request for services form

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Request Services for Your Child
Fill out a request for services form