Intake Form Name of Person Completing Form* First Last Who is completing this form?*Parent/Caregiver/GuardianExternal Referral SourceEmail*Phone Number*Primary Language Spoken*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Insurance Information for ABA CoverageWhat insurance coverage(s) do you have?* Aetna Blue Cross Blue Shield Cigna First Choice Health Network Kaiser Premera Regence United Healthcare Medicaid Managed Care: Amerigroup Medicaid Managed Care: Community Health Plan of WA Medicaid Managed Care: Cooridinated Care Medicaid Managed Care: Molina Medicaid Managed Care: United Healthcare Other Please select all insurance carriers that you have. If you are unsure or your plan is not listed, you may select 'other'. If your plan is not listed, we may not be in-network with your insurance.If you selected 'other', what insurance?EmployerGroup IDIndividual Insured ID NumberPrimary Insured Name First Last Name of client for child you would like to enroll* First Last Date of birth of client or child you would like to enroll* Date Format: MM slash DD slash YYYY Has your child been diagnosed with Autism Spectrum Disorder (ASD)?*DiagnosisYesNoPendingAre you receiving ABA services from another provider?ABA ServicesYesNoIf yes, what provider?What services are you interest in?* Select All Summer Center-Based Services In-Home Services Parent Training/Coaching Consultation Social Skills Group Summer Session Options AM Session: 3 hours between 8 am and 12 pm PM Session: 3 hours between 12 pm and 4 pm Center Session Options Select All Kent AM Session: 8 am to 11:30 am Kent PM Session: 12:30 pm to 4:00 pm Kirkland AM Session: 8 am to 11:30 am Kirkland PM Session: 12:30 pm to 4:00 pm Lynnwood AM Session: 8 am to 11:30 am Lynnwood PM Session: 12:30 pm to 4:00 pm In-Home Session Options Select All AM Session: range within 8:00 am and 12:00 pm PM Session: range within 12:00 am and 4:00 pm Evening Session: Between 4-7pm For In-Home sessions, exact times and days of week would be determined during intake depending on your child need's and staffing availability.Please upload a copy of your child's diagnostic evaluation, insurance card(s) front/back, and any other medical documentation you would like us to review for intake processing. Documents are upload securely to our clinical team. Drop files here or Accepted file types: jpg, gif, png, pdf, doc, docx. Consent* I consent for Connections to contact my insurance company to verify eligibility and benefits.Disclaimer* I understand that signing up for a service does not guarantee my a spot.The next step is for us to process the documents you submitted. Please be reminded that completing the forms does not guarantee a spot and there might be a wait before services start. We will be in touch with you within 3-5 business days.
