Service Referral

Service Referral
Patient Information
Patient Name
Date of Birth

MonthDayYear
Age
Calculation
Gender
Closest Kind Behavioral Health Location
Please indicate reason for referral:
Does Patient have a medical diagnosis (F84.0) of Autism Spectrum Disorder (ASD)?
Does Patient require a diagnostic evaluation to confirm a medical diagnosis of Autism Spectrum Disorder(ASD)?
Contact Type
Insurance Provider
Do you have active medical insurance?
Please Select your active insurance provider (s)
GA-Do you have active medical insurance?
GA-Please Select your active insurance provider (s)
Does the family require language assistance? (ex. Phone Translating services)
If so, please note the preferred language
Thank you for your interest in referring to Kind Behavioral Health.

A Diagnosis of F84.0 ASD is required for ABA services with Kind Behavioral Health. If you have any questions, please email referrals@kindbh.com
Parent / Guardian Information
Parent / Guardian Name
Last
Email-(If you do not have a parent email, please use this format: clientfirst name.lastname@noemail.com)
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referral Source Information
Referral Source Name
Last Name
Email
Phone Number
Format: (000) 000-0000.
Fax Number
Format: (000) 000-0000.
NPI Number (If Applicable)
Practice Name (if Applicable)
Referral Application Completed by:
Additional Notes:
Ex: Reason for referral
Date of ASD Diagnosis

MonthDayYear
Date of Original Diagnosis

MonthDayYear
Diagnostic Severity Level
Date

MonthDayYear
Region
Meets Criteria-NC Medicaid
Parent Guardian Full Name
Referral Full Name
Dx Confirmed
Meets Criteria
Region
Address
Source
Should be Empty:

Service Referral

Patient Information

Parent / Guardian Information

Referral Source Information