Intake Form

"*" indicates required fields

Client Name*

First Last

Date of Birth*

Parent Name*

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

E-mail address*

Phone*

Gender*

Reason for referral*

Address of school and hours (if applicable)

Does the client have an autism diagnosis?

Yes

Does the child have a diagnosis other than autism? If so, what is the diagnosis?

Where were they diagnosed? When were they diagnosed?

Date of diagnosis?

Primary Insurance*

Name of policy holder/Insured*

Relationship to client*

DOB of policy holder*

Address (if different from the client's)

Name

First Last

Relationship to client

Phone number

Parent Signature*

By checking this box, you agree to be contacted by a coordinator at Elle & Me.

Is there any additional information that you would like to share with us?

Who should we thank for the referral?

ENJOY A FREE SESSION!