Enroll – Comprehensive Disability Services

Enrollment Form

Date

Person Completing this form

Relation to child

Reason to visit

Child's Name

Child's Address

Child's Nick Name

Child's Date of Birth

Child's Age

Child's Gender

Male Female Other

Phone Number

Child's Siblings

Mother's Name

Mother's Telephone

Mother's Age

Father's Name

Father's Telephone

Father's Age

Address

Marital Status

Primary Care Physician Name and Address

Behaviors

Child's Diagnosis

Other Diagnosis

How was your child diagnosed?

When was your child diagnosed?

Evaluation Date

Re-evaluation Date

Did your child participate in Early Intervention services and supports?

Male Female Other

Where did your child participate in Early Intervention services and support?

Is your child in any special education classes?

Yes No

Has your child recived Applied Behavior Analysis therapy?

Yes No

Provider Name

Provider Address

What are the other medical necessary services your child is receiving?

What are your goals for your child with ABA therapy?

Copayment

Yes No

Copayment Amount

Health Plan Name

Group Number

Member ID Number

Additional Insurance Information

Child's Name

Child's Date of Birth

Child's Age

Signature Patient

Printed Name (Patient)

Date (Patient)

Signature (Witness)

Printed Name (Witness)

Date (Witness)

Enrollment Form

Washington DC Office

Maryland Office

Address 1

Address 2