Enhanced Living Centers Referral/Intake Form Person completing form:(Required) How did you hear about Enhanced Living Centers?(Required) Relationship to client:(Required) Email:(Required) Phone Number:(Required)Client's First and Last Name:(Required) Client's DOB:(Required) MM slash DD slash YYYY Primary Contact First and Last Name:(Required) Primary Contact Relationship to Client:(Required) Is primary contact also legal guardian?(Required) Yes No Legal Guardian First and Last Name:(Required) Relationship to Client:(Required) Primary Phone #:(Required)Primary Email:(Required) Primary Address:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Placement:Client lives at homeClient is currently in the hospitalClient is in a group homeOtherPlease include details if Other or hospital selected 155 charactersSecondary Contact First/Last Name:(Required) Secondary Contact Phone # and/or Email:(Required) Services Needed (Select All That Apply):(Required) ABA Habilitation Respite Attendant Care Group Home Placement Primary Physician's Name:(Required) Primary Physician's Phone Number:(Required)Client's School:(Required) School Attendance Days and Times:(Required)Client's Current Services:(Required) Therapy Location/Agency:(Required) Any Medications?(Required) Yes No If Yes, Please Specify Medications:If available, provide name & contact information for Insurance Contact or Care Advocate: Primary Insurance Company Name:(Required) Primary Insurance Policy Holder Name:(Required) Primary Insurance Policy Holder DOB:(Required) MM slash DD slash YYYY Primary Insurance Policy Holder Employer:(Required) Primary Insurance Policy Number:(Required) Primary Insurance Group Number:(Required) Does the client have secondary insurance?(Required) Yes No Secondary Insurance Company Name:(Required) Secondary Insurance Policy Holder Name:(Required) Secondary Insurance Policy Holder DOB:(Required) MM slash DD slash YYYY Secondary Insurance Policy Holder Employer:(Required) Secondary Insurance Policy Number:(Required) Secondary Insurance Group Number:(Required) Please upload the following documents: 1) Insurance Cards front and back.File Upload(Required)Max. file size: 100 MB.2) Prescription for ABA services.File UploadMax. file size: 100 MB.3) Copy of Diagnostic Evaluation completed by a Doctor.File UploadMax. file size: 100 MB.PhoneThis field is for validation purposes and should be left unchanged.
