Access Family Services

Application for ABA Services

    Instructions:

    Please complete the following information and submit online. You can also download this form from our website, fill out on your computer and print, scan and email to autismservices@accessfamilyservices.xyz, or print and fax to 919-896-6443.


    Date:

    Referred By: (required)


    Referral Agency Number: (required)


    Client Information:


    Last Name, First Name Middle Initial:
    ,

    Email Address:

    DOB:

    Home Address

    ,

    Sex:
    MF

    Race: (Optional)

    SSN:

    County:




    Contact Information:


    Parent or Legal Guardian Contact 1:(required)

    Name: Relationship to Client:

    Mobile Phone: Home Phone:

    Email Address:

    Address (if different from client):



    ,

    Primary Language:


    Parent or Legal Guardian Contact 2:

    Name: Relationship to Client:

    Mobile Phone: Home Phone:

    Email Address:

    Address (if different from client):


    ,

    Primary Language


    Insurance Information:


    Primary:

    Company / Type:
    /

    Policy Holder Name: DOB:

    Subscriber ID: Effective Date:


    Secondary:

    Company / Type:
    /

    Policy Holder Name: DOB:

    Subscriber ID: Effective Date:


    Reason for Referral/Primary Concerns about the Client:


    During the intake process we will be requesting detailed information regarding your child’s history, current needs, and caregiver concerns. Please identify your top three concerns that you would like addressed during the first 6 months of treatment.

    1.

    2.

    3.

    You will be hearing from us within 72 hours. At that time a member of Access Family Services will be requesting a copy of a signed diagnostic or psychological evaluation confirming a diagnosis of Autism Spectrum Disorder(F84.0).

    Select Your Preferred Location:


    HIPAA Compliance

    As a client of Access Family Services, a record of health information is made. In adhering to our Best Practices for HIPAA Compliance, we have made our HIPAA, Confidentiality & Privacy Practices document available for download.

    HIPAA, Confidentiality & Privacy Practices
    [Download]

    Client Rights Handbook

    As a service to Access Family Services clients,, we have made our Client Rights Handbook available for download.

    Client Rights Handbook
    [Download]

     

    Client Rights Handbook
    (En Español)
    [Download]