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Registration for Social Skills Group for Children with Autism Spectrum Disorder
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Client's First Name, Middle Initial, Last Name *
Session to Register for:
Client's Date of Birth *
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/
DD
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YYYY
Client's Primary Home Address *
Father's First Name, Last Name *
Father's Email
Father's Cell Phone Number
Mother's First Name, Last Name *
Mother's Email *
Mother's Cell Phone *
Insurance Carrier *
Insurance Member ID # *
Group ID#
Insurance Policy Holder's Name
Insurance Policy Holder's Date of Birth
PCP or Pediatrician's Name, address, phone
Has this client received speech therapy previously?
Please describe your child's history of language delay (age of diagnosis, services being received, family goal for communication mode)
Please describe your current speech and language concerns:
How would you like to receive services?
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Would you be interested in a Parent Education Class to learn how to help your child at home?
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How did you hear about A Sound Beginning, LLC?
Do you give permission for A Sound Beginning, LLC to direct bill your insurance company and be reimbursed directly for any medical services performed?
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Do you understand that any financial responsibility you have for copays, deductibles, group tuition, and balances not covered by insurance will be billed directly to the policy holder/parent/guardian?
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