Application for ABA Therapy at The Place for Children with Autism
Parent / Guardian Information
Parent/Guardian Name
*
First Name
Last Name
Secondary Parent / Guardian Name
First Name
Last Name
Street Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number 2
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Language
*
Please Select
English
Spanish
Other
Program of Interest
Please Select
ABA Therapy
ABA Therapy with Speech Therapy
After School Program
Child Information
Child's Name
*
First Name
Last Name
Child's Age:
*
Address (If different than parent / guardian)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Autism Spectrum Disorder Diagnosis:
*
Please Select
Yes
No
Pending
Unsure
Diagnostic Report of Autism
Please Select
My child has been evaluated for Autism, and I have a copy of the diagnostic report.
My child has not been evaluated for Autism, and I need help scheduling with a diagnostician.
My child has not been evaluated for Autism, but an evaluation is already scheduled.
My child has received an Autism diagnosis, but I do not have the diagnostic report and would like your assistance in requesting it.
Diagnostic Scheduling Acknowledgement
*
Yes- I would like help scheduling with a diagnostician and understand that if autism is diagnosed, I may choose to enroll in ABA services at The Place.
No- I would like help with diagnostic scheduling only at this time.
Has your child received ABA therapy within the last 6 months
*
Please Select
Yes
No
Unsure
Preferred Location
*
Please Select
Aurora
Bloomington
Bronzeville
Champaign-Urbana
Cicero
Elgin
Hermosa
Jefferson Park
Joliet
Lake in the Hills
Mt. Greenwood
Oak Lawn
Orland Park
Other/Undecided (Illinois)
Other (out of state)
Pilsen
Portage Park
Rogers Park
River North
Waukegan
First Available
Alternative Locations I would consider:
Please Select
Aurora
Bloomington
Bronzeville
Champaign-Urbana
Cicero
Elgin
Hermosa
Jefferson Park
Joliet
Lake in the Hills
Mt. Greenwood
Oak Lawn
Orland Park
Other/Undecided (Illinois)
Other (out of state)
Pilsen
Portage Park
Rogers Park
River North
Waukegan
First Available
Insurance Information
Insurance Name
*
Please Select
Anthem
Blue Cross Blue Shield
Cigna
Compysch
Endeavor Health
Health Alliance
Labor Fund
Self-Funded Policy
UMR
United
Other
Do you have Medicaid:
*
Please Select
Yes
No
Unsure
You selected Medicaid only however, we do not accept Medicaid. If any of these situations are true for you, you may be eligible for Special Enrollment for Private Insurance & we can assist you: If in the last 60 days you:
Got Married or divorced
Had a baby
Lost job and employer sponsored insurance
Moved to Illinois from another state
None of these apply
Other Source of Insurance?
*
Do you have another active insurance plan (excluding Medicaid)
Policy ID
Group #
Is your child on this insurance plan currently?
*
Yes
No
Unsure
Primary Guarantor (Name of parent in which insurance is under):
*
Guarantor Date of Birth:
*
-
Month
-
Day
Year
Date
Name of Employer
*
Other
How did you hear about The Place for Children with Autism:
*
Please Select
Internet Search
Physician
Relative / Friend
School / Daycare
Social Media
Walk-In / Drive-By
Other
When is the best time to reach you:
*
What is the best method of communication:
Please Select
Email
Phone
Both
Insurance Card Upload
Front of Insurance Card
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Back of Insurance Card
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Signature
I hereby submit this application to The Place for Children with Autism and I understand that this application does not guarantee admission for treatment.
*
Upload the Medical Diagnostic Report for Autism Here (ASD)
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Name of Diagnostic Provider you are scheduled with:
Date of Scheduled evaluation:
-
Month
-
Day
Year
Date
Patient's Name for HIPPA form:
First Name
Last Name
Patient's Date of Birth for HIPPA form:
-
Month
-
Day
Year
Date
Authorized Caregiver/Representative Name for HIPPA form:
First Name
Last Name
Relationship to Patient for HIPPA form:
I, as authorized representative for patient's name, do hereby grant The Place for Children with Autism (DJJE Holdings, LLC) with permission to use and disclose protected health information related to the applicable patient's file:
Please Select
Yes
No
Name of Location where evaluation occurred:
Name of Doctor who completed the evaluation:
Specific Information to be Released/Obtained:
Please Select
Diagnostic Evaluation of Autism
This medical information may be used by the person I authorize to receive this information for medical treatment, consultation, billing or claims payment, or other purposes as I may direct. I understand that I have the right to revoke this authorization, in writing, at any time by written notification to DJJE Holdings, LLC. at 8609 W Bryn Mawr Ave, Suite 204, Chicago IL 60659 ATTN: Privacy Officer. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest this claim. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on the signing of this authorization. If I have authorized the disclosure of client information to someone who is not legally required to keep it confidential, state or federal privacy laws may no longer protect it and the information may be disclosed. I understand that I have a right to receive a copy of this authorization for my records. By signing this form, I am authorizing the entity designated above to use and disclose protected health information from/to The Place for Children with Autism (DJJE Holdings, LLC.)
Today's Date:
-
Month
-
Day
Year
Date
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By signing, I acknowledge receipt and acceptance of this Notice of Privacy Practices and how it relates to my protected health information.
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Submit
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