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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin 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? Employer Group ID Individual Insured ID Number Primary 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* MM slash DD slash YYYY Has your child been diagnosed with Autism Spectrum Disorder (ASD)?*DiagnosisYesNoPendingWhat are your top three priorities for your child? First priority (highest, most important) Second priority? Third priority? Are you receiving ABA services from another provider?ABA ServicesYesNoIf yes, what provider? What services are you interest in?* Select All In-Home Services Parent Training/Coaching Consultation Social Skills Group In-Home Session Options Select All Between 8:00am and 12:00pm Between 12:00pm and 4:00pm 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 Select files Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 250 MB. Note: All documents must be received to officially add your child to the waitlist.Disclaimer* I understand that my child’s documents must be uploaded to be added to the waitlist.Disclaimer* I understand that signing up for a service does not guarantee me 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.Consent* I consent for Connections to contact my insurance company to verify eligibility and benefits.How did you hear about us? internet search Kindering Seattle Children's a friend Facebook insurance company my child's school other other CAPTCHA
