Pre-Assessment
This form will be used to asses the needs of the individual to determine if Learning Lightbulb Interventions will be a good fit. It is in no way a guarantee of services. We strive to connect service provider specialties with the needs of the individual by "making the best fit possible".
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Email *
Basic Information
Name of Individual *
Age of Individual *
Date of Birth of Individual *
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Social Security Number of Individual (if known)
Address *
City, State, Zip *
Legal Guardian *
Contact Number *
Relationship to Individual *
Additional Legal Guardian
Contact Number
Relationship to Individual
Clear selection
Case Manager (if applicable)
Case Manager's Contact Number/Email (if applicable)
Who referred the individual? *
Which of these best describes the individual's communication? *
What is the individual's primary language? *
Please list the name of everyone living in the primary household: *
Please list the name of everyone living in the secondary household: (if applicable)
Primary Insurance: (Note: Commercial Policies are through a workplace or insurance broker. HSAs are self-funded policies. Medicaid is through the state of Kentucky.) *
Subscriber Name (Policy holder) *
What is the policy owner's ID number? *
MAID number (if medicaid)
Does the individual have a secondary insurance? (If yes, please list type as "other") *
Secondary Policy Type (Carrier) and ID#
Do you have a current Autism diagnosis (within the last 3 years)? *
Does your child require medications to be given throughout the day in your absence or by a medical professional? *
Medication Allergies (ie: Latex, Penicillin, Asprin) If no allergies mark "N/A" *
Food Allergies (ie: shellfish, peanuts) If no allergies mark "N/A" *
Environmental Allergies. (ie: dust, pet dander) If no allergies mark "N/A" *
Other Allergies (ie: metals, red dye) If no allergies mark "N/A" *
School attending ("NONE" if not applicable) *
School District (Shelby County, Spencer County, N/A if not applicable and so forth) *
Which of the following does the child currently have? *
Current medications the individual is taking: *
Who prescribed this/these medication(s)?
Is the individual on any other over the counter, NON-PRESCRIPTION medications? Please list. *
Who is the child's Pediatrician or Family Doctor? *
Does the individual have a history of psychiatric hospitalization? *
Date of Last Hospitalization (if applicable)
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Which of the following services has the individual RECIEVED IN THE PAST, but is NO LONGER RECIEVING? *
Required
Which of the following services are the individual CURRENTLY RECEIVING? *
Required
Behavioral Struggles (difficulties the client may be struggling with) please check all that apply: *
Required
As the caregiver, what are your TOP THREE (3) biggest behavioral concerns. Please describe. *
Please email copies of the following needed documents  to our intake coordinator at admin@learninglightbulb.com (items marked with * are required). You may also do so by replying to the email that contained this form. Please check each box that you can send right away. (NOW IS THE TIME TO WRITE THIS DOWN!) *
Required
What are some things that the individual likes to do or play with? *
Disclaimer: Once you have completed the Guardian Consents and this form, you will be added to the wait list. You will be contacted once we have availability matching your request. At that time, you will be contacted to set up an in-person follow up visit where you will be asked to complete additional forms. Once these forms have been reviewed, a final visit will be completed for insurance purposes. Although we accept many forms of payment such as insurance and waiver, you can opt-in to the wait list for private pay as well. Should your information need to be updated at any time, including address, availability, contact number or payment information, please contact us to make those changes immediately. *
Disclaimer: I understand that my insurance will typically only pay for ONE (1) assessment every THREE (3) to SIX (6) months. I understand that if I have had an assessment in that time or if I plan to get another assessment within the next THREE to SIX months, I may be responsible for the charges denied by the insurance company due to this. This does not include psychiatric evaluations/assessments done with a Psychologist or Psychiatrist. Please initial to acknowledge your understanding. I further understand that if services are received and I am not currently insured I will be charged the full price of the services. *
By typing my name, I assert that the information I have given is accurate to the best of my knowledge and will be treated as my electronic signature. *
By typing my name, I assert that the information I have given is accurate to the best of my knowledge and will be treated as my electronic signature. (Court Appointed Person)
Date *
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