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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 (CCO’s)

  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.