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:*

Autism Diagnostic Evaluation (client does NOT have a confirmed ASD-F84.0 diagnosis)ABA Therapy (client DOES have a confirmed ASD-F84.0 diagnosis)
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)

NC MedicaidTricareBlueCross Blue ShieldCignaAetnaUnited HealthcareNorth Carolina State Health PlanMedcostOther
GA-Do you have active medical insurance?
GA-Please Select your active insurance provider (s)

TricareCignaUnited HealthcareGA Medicaid-DirectGA Medicaid-AmerigroupGA Medicaid-Peach State Health PlanGA Medicaid-CareSourceOther
Does the family require language assistance? (ex. Phone Translating services)*

YesNo
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*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referral Source Information
Referral Source Name*
Last Name
Email*
Phone Number*
Fax Number*
NPI Number (If Applicable)
Practice Name (if Applicable)
Referral Application Completed by:*

Kind Behavioral Health StaffExternal Medical Provider Staff
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
Region
Address
Source*

Referral
Should be Empty:

Service Referral

Patient Information

Parent / Guardian Information

Referral Source Information