Refer a Patient

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first row

Date of referral

Name of submitting provider

Clinic/practice name

second row

Clinic phone

Clinic fax

Clinic contact

Layout

third row

Email address

Phone number

Is patient aware of referral?

Address

Address Line 1

City

State

Zip Code

Layout (copy)

Insurance information row

Primary Insurance

Policy holder

Supporting documentation checklist

The patient’s comprehensive diagnostic evaluation (if available) that includes standardized testing and scores signed by a Physician (MD/DO) or a Clinical Psychologist.
A referral for therapy that is signed by a Physician and includes a diagnosis code for Autism Spectrum Disorders (F84.0).
A copy of the patient’s annual physical that was completed within the past year. (Required for Massachusetts only)
All information is contained on the submitted documents

Diagnostic evaluation (.doc, docx, .pdf)

Referral for ABA therapy (.doc, docx, .pdf)

Patients annual physical that was completed within the past year (Required for Massachusetts only) (.doc, docx, .pdf)