Apply for Services

Finding balance starts here.

At Balance Autism, we're here to support individuals and families with compassionate care and innovative services.

Before you begin, please have the following documents available if possible. Documents can be uploaded with your application or submitted later.

Documents We Need

Autism diagnosis evaluation
Most recent IEP, ISP, IPP, or similar plan
SIS Evaluation (adults only)
Medicaid and/or insurance information

Note: Not all documents are not required for Speech Therapy, Occupational Therapy, or neurotypical peers applying for preschool.

You may still submit your application if you do not have these documents available today.

Applicant Information

Applicant First Name

Applicant Last Name

Is the applicant currently receiving any services from Balance Autism?

YesNo

Current Services Received

Services

Location

Gender

Date of Birth

MM/DD/YYYY or MM-DD-YYYY

Age


Applicant Address	Street State City Zipcode

Referral Information

What is your relationship to the applicant?

Relationship to Applicant - Other

Your First Name

Your Last Name

Phone

Email

How did you hear about us?

Other - Referral Name

Name of School

Name of Community

Name of Psychologist/Psychiatrist

Name of Case Manager

Name of Physician

Name of Family Navigator

Are you the legal guardian?

YesNo

Is your address same as applicant?

YesNo

Guardian Information

Guardian's First Name

Guardian's Last Name

Guardian's Primary Phone Number

Guardian Email


Guardian Address	Street State City Zipcode

Guardian Address

Street

City

State

Zipcode

Guardian's relationship with applicant?

Guardian Relationship - Other

Is there a second guardian?

Guardian 2

Guardian's First Name

Guardian's Last Name

Guardian's Primary Phone Number

Guardian Email


Guardian Address	Street State City Zipcode

Guardian's relationship with applicant?

Guardian Relationship - Other

Is English the preferred language spoken at home?

YesNo

Preferred Language

What is the primary preferred language spoken in the home?

Is this primary language preferred by the guardian?

YesNo

Does the child speak this language?

YesNo

Does this child understand this language when it's spoken?

YesNo

Please indicate what language the child understands best?

Have you previously been in contact with a representative from Balance Autism?

YesNo

Would you like to receive text alerts

Applicant Insurance Information

Primary Insurance

Policy Holder's Date of Birth

MM/DD/YYYY or MM-DD-YYYY

Policy Holder's First Name

Policy Holder's Last Name

Policy Holder's Relation to Applicant

Other Relation - Please Specify

Currently the insurance provider you selected does not cover ABA services. For other funding possibilities, please contact the Iowa Autism Support Program, or Iowa Medicaid to see if the child’s diagnoses might be covered under for waiver services.

Other - Primary Insurance

Is the applicant currently covered by any other insurance?

Secondary Insurance

Policy Holder's Date of Birth

Policy Holder's First Name

Policy Holder's Last Name

Policy Holder's Relation to Applicant

Other Relation - Please Specify

Other - Secondary Insurance

Medicaid Number/ Title 19 Number

Does the applicant have a case manager?

YesNo

Case Manager Information

First Name

Last Name

Phone Number

Email

Case Manager Additional Information

County of Financial Responsibility

Approved Medicaid Funding

Other - Approved Medicaid Funding

Has the applicant applied or has been approved for funding through the Iowa Autism Support Program (ASP) funding?

Medical Information

Medical Information

List all diagnoses.
Applicants must be diagnosed with autism spectrum disorder to receive services from Balance Autism. There are exceptions to this rule - no autism diagnosis required - for preschool and speech, occupational, feeding, and tongue-tied therapies.

	Yes	No
Does the applicant have any physical limitations?

Please describe the physical limitations.

If the applicant has any physical limitations, please list any adaptive devices (i.e. wheelchair, shoe inserts, braces, walkers, etc.)

	Yes	No
Has the applicant had any seizures?

Please provide a brief description of the type, frequency and severity.

	Yes	No
Does the applicant take any prescription medication?

Prescription Medication

Medication

Frequency

Dosage

	Yes	No
Does the applicant have any allergies?

Allergy Information

Type of Allergy

Reaction

How does the applicant communicate?
Select all that apply

Please hold the CTRL key to select multiple values from this list.

Other - How does the applicant communicate?

Where does the applicant need the most support?

Please limit your selection to 5 of the applicant's most important support areas

Please hold the CTRL key to select multiple values from this list.

Other - Area Applicant Needs Most Support

Please describe

When was your child's last physical exam?

Are your child's immunizations up-to-date?

YesNo

Attachments

The following items are needed to complete the applicant's file. This application might be submitted without supporting documentation. However, all remaining items must be received before an applicant will be added to our waiting list.

Attachments

For all services except SLP, OT and preschool, applications must show proof of diagnostic testing.

Do you have access to upload the diagnostic psychological evaluation in this application?

YesNo

This information can be submitted at a later date, but the application won't be complete until this is received.

Would you like assistance requesting this document?

YesNo

Please upload the applicant's Psychological Evaluation Specifically for ABA services, this report must: - List autism diagnosis - Be conducted by licensed psychologist or developmental pediatrician - Explain which autism-specific assessment tool was used and scores

Please enter the month and year of the last psychological evaluation.

Month

Year

Over 3 Years

Your insurance carrier may require updated psychological evaluation every 3-5 years. Please check with your insurance company, and schedule that next appointment soon.

Please upload the applicant's Individual Service Plan, if applicable
An IEP from School, ISP/IPP/IFSP from other service providers.

Are you able to upload insurance card information today?

YesNo

Please upload Primary Insurance Information
A copy or picture of the insurance card. If you have insurance that is not Medicaid, please attach pictures of both sides of the card. FRONT

BACK

Please upload Secondary Insurance Information
Please send a copy or picture of the insurance card. If you have insurance that is not Medicaid, please attach pictures of both sides of the card. FRONT

BACK

Please upload Support Intensity Score Evaluation (InterRAI) if available

Please upload a most recent Case Management Release of Information

Please upload the release of information document signed by the guardian which authorizes communication between case manager and Balance Autism.

Additional Documentation 1

If you would like to provide any additional information, please add it here.

Please select the type of other additional documentation you would like to provide.

Admission Form for Individuals with Autism

Apply for Services

Finding balance starts here.

Services

Medical Information

Occupational/Speech Therapy

Speech Therapy

Attachments

The following items are needed to complete the applicant's file. This application might be submitted without supporting documentation. However, all remaining items must be received before an applicant will be added to our waiting list.

Admission Form for Individuals with Autism

Apply for Services

Finding balance starts here.

Services

Medical Information

Occupational/Speech Therapy

Speech Therapy

AttachmentsThe following items are needed to complete the applicant's file. This application might be submitted without supporting documentation. However, all remaining items must be received before an applicant will be added to our waiting list.

Attachments

The following items are needed to complete the applicant's file. This application might be submitted without supporting documentation. However, all remaining items must be received before an applicant will be added to our waiting list.