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 selected155 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.
