Admission Form

APPLY FOR ADMISSION

With innovative therapy and compassionate care, we’ll help you find balance…for family, for community, for life.

Before starting the application for services, it will be helpful to have the following document ready to upload. (This information may also be forwarded to us at a later time).

· Medicaid and/or insurance information

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

Preferred Language of Communication

Other - Preferred Language of Communication

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

Preferred Language of Communication

Other - Preferred Language of Communication

Would you like to receive text alerts

Medical Information

Medical Information

List any medical diagnoses.

	Yes	No
Does the applicant require any emergency medications?

Prescription Medication

Medication

Frequency

Dosage

	Yes	No
Does the applicant have any allergies?

Allergy Information

Type of Allergy

Reaction

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

Other - Primary Insurance

Medicaid Number/ Title 19 Number

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

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

Attachments

If you are applying for speech or occupational therapy, a copy of the insurance card is needed to complete the applicant's file. This application can be submitted without the document. However, the copy of the insurance card must be received before an applicant will be added to our waiting list. No documents needed for preschool applications.

Do you have documents to upload at this time?

Attachments

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.

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.

Please upload a valid 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.

Do you have additional documents you want to include with this appilication?

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.