Autism Referral

An autism diagnosis is required for ABA services. Services will not start until a diagnostic report or verification is provided. Please attach ABA documentation and a copy of insurance card, if applicable, in upload section below.

Autism Services Referral Form

Date

Referral Source (name/agency)(Required)

Client Name(Required)

First Last

Client Date of Birth(Required)

Client Age(Required)

Client Gender(Required)

Client Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Name (Required for clients under the age of 18)(Required)

First Last

Relationship to Client(Required)

Parent/Guardian Phone Number(Required)

Parent/Guardian Email Address

Providing an email address, if available, helps us connect you to needed services as efficiently as possible.

Current Services & Providers(Required)

Current Tanager Place client?(Required)

Yes

Date of Diagnosis

Recommended/Requested Services

Autism Services

ABA Services (include documentation showing medical diagnosis below)

Social Skills Group

Reason for Referral:(Required)

Please include information about current symptoms, behaviors, functioning and trauma. Do these occur in the home, school, community, or across all settings?

Primary Insurance

Insurance verification is required before appointment. While insurance information is not required as part of this form, providing it now will expedite the path to treatment.

Insurance Carrier (include MCO if applicable)

Name on Insurance Card

First Last

Date of Birth (if different than client)

Subscriber/Member ID

Secondary Insurance (if applicable)

Insurance Carrier (include MCO if applicable)

Name on Insurance Card

First Last

Date of Birth (if different than client)

Subscriber/Member ID

Insurance & Documentation Upload

Drop files here or

Accepted file types: jpg, pdf, png, gif, Max. file size: 256 MB.