Autism Program Referral Form
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1Autism Program Referral Form
Patient Contact Information
Patient Name: ____________________________________________________ DOB: _____________
Street Address: ___________________________________________________
Gender: _________
City: ___________________________ State: __________ Zip Code: ____________
Parent/Guardian Name(s): __________________________________ Phone: _____________________
Insurance Company: ___________________________ Member Number: ________________________
Group Number: _____________ Subscriber Name: _________________________ DOB: ___________
Services Requested (Check all that apply)
Service
Description
Requirements
Diagnostic Testing
Testing to determine if patient meets
We are currently unable to accept
DSM-5 criteria for Autism, or to
OHP-Healthshare or Molina (WA
reevaluate if previous testing occurred
only).
more than 3 years ago.
Applied Behavior Analysis
Our most intensive service for patients
Patient must have current diagnosis
with significant difficulties
of Autism Spectrum Disorder and
(ABA)
communicating, behavior problems, or
be within the ages of 2.5-17 years
social skill deficits.
old. We are currently unable to
accept OHP or Molina (WA only).
Mental Health Treatment
Traditional mental health therapy for
Ages and specialties vary by
patients with Autism Spectrum Disorder
location.
and comorbid depression, anxiety,
ADHD, etc.
Social Skills Group
Groups utilize evidence-based PEERS
Groups run once there are enough
curriculum.
participants in an age group. Parent
participation required.
Referring Provider Information
Name: ____________________________________
Clinic: _______________________________
City, State: _________________________________
Phone: ____________________________________ Fax: ________________________________
Office Contact (if not referring provider): ___________________________________________
Please fax completed form to 503-233-2694
For office use only:
Date request received ________ Received by ________________________________
Request Approved (If no, give reason)
Yes
No ______________________________________________
_________________________________________________________________________________________
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