CONFIDENTIALITY AGREEMENT: LaHaye and Doll ABA Services will not purposefully share, post, or alter personal or medical information with any person, professional, or company without consent.

Diagnostic Information

PLEASE READ BEFORE CONTINUING:

All prospective clients require an:

Official diagnostic report (CDE) that includes the evaluation used to diagnose for ASD. This information can be provided by the diagnosing physician. If you need assistance acquiring this document, you will need to sign an Authorization to Release Medical Information. Please call our office for more information.
A referral for ABA therapy
A copy of their insurance card(s), front and back

You must upload the minimum THREE files required.

Optional files include IEPs, previous treatment plans from other ABA clinics, etc.

Medical Documents

Refer to important information above. We require ALL 3 documents to be placed on the waiting list.

Client Name (First, Last)

Date of Birth

Month

Day

Year

Today's Date

Month

Day

Year

Parent Phone Number

If information is missing from your uploaded documents, office staff will attempt to contact you for revisions and additions to your child's referral file.

Parent/Guardian Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Once the "Submit" button has been pressed, you will be redirected to the next portion of our intake process.