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Application for In-Home Behavioral Consultation

  1. Application for In-Home Behavioral Consultation
    for School Aged Children, Youth, Young Adults with Autism Spectrum Disorder
  2. Section I - Application Information
  3. Sex*
  4. Provisional Eligibility
  5. Section II - Family/Caregiver Contact
  6. Relationship*
  7. Custodial Parent*
  8. Legal Guardian:*
  9. Relationship
  10. Custodial Parent
  11. Legal Guardian
  12. Section III - Current Situation
  13. Imminent or Increasing Risk of:
  14. Current Situation
  15. Section V - Reason For Referral
  16. Reason for Referral*
  17. Physical Aggression
  18. Medication Taken to Manage Problem Behavior
  19. Section VI - Communication
  20. Method of Communication*
  21. Section VII- Primary Language if not English
  22. Language
  23. Section VIII - Qualifying Developmental Disability Diagnosis/Condition
  24. Autism Spectrum Disorder (Inc. Aspergers, PDD, Autism)*
  25. Section IX - Behavioral Health Conditions
  26. At least One Current Mental Health Diagnosis*
  27. Medication Taken to Manage Symptoms
  28. At least One Current Substance Use/Abuse Diagnosis
  29. Medication Taken to Manage Addiction
  30. Prominent Physical/Health/Medical Conditions, Concerns, Alerts*
  31. Epilepsy
  32. Medication Taken to Manage Physical/Health/Medical Conditions
  33. Section X - Add here any information of a sensitive nature that will assist in prioritizing this request. Please be brief and concise or submission may not come through.
  34. Section XI - School Information
  35. Other
  36. Services
  37. Section XII - Current Authorized Service(s) (check all that apply)
  38. Current Authorized Service(s)
  39. Section 13 - Care Management Provider
  40. Care Coordinator Organizations (CCOs)
  41. Please Submit ISP or LIFEPlan and if Applicable IEP and School Assessment (OT, PT, Speech, Psych)
  42. Leave This Blank:

  43. This field is not part of the form submission.