ALP Insurance Form

The team at Autism Learning Partners understands that getting an autism diagnosis is hard and getting insurance coverage for your child is very difficult and time consuming. That’s why the ALP intake team is here to help.  By filling out the secure document below, we can check your plan and make sure you can get the services your family needs now.  We have done this for hundreds of families and can help you too!  Don’t go it alone, we have done all the research, have relationships with the insurance companies, and we want to help.

Once you fill out the secure form, click submit and your application will be reviewed and worked by our care management team.

We look forward to getting you the help and services you need.


CLIENT INFORMATION


Client's Full Name (required)

Address (required)

City (required)

State (required)

Zipzode (required)

Date of Birth (required)

Diagnosis

Sex (required)


PRIMARY GUARDIAN INFORMATION:


Legal Full Name (required)

Email Address (required)

Address (required)

City (required)

State (required)

Zipzode (required)

Relationship to Client (required)

Primary Phone Number (required)

Secondary Phone Number

Employer

Social Security Number (required)


INSURANCE INFORMATION:


Primary Insurance Company (required)

Primary Insurance Policy ID# (required)

Primary Insurance Group # (required)

Primary Insurance Phone Number (required)


Secondary Insurance Company

Secondary Insurance Policy ID#

Secondary Insurance Group #

Secondary Insurance Phone Number


Are You Receiving State Funded Insurance? (required)

If "Yes" - State Plan and ID Number


Policy Holder's Name (required)

Relationship to Client (required)

Date of Birth (required)


SERVICE OFFERINGS:


Services Interested In (Check all that Apply)
Applied Behavioral AnalysisCommunity ServicesHome ServicesOccupational TherapyPhysical TherapySchool ServicesSocial SkillsSpeech Therapy


Availability For Sessions:


At Autism Learning Partners, we provide services from 8am-8:30pm Monday – Friday and various times on Saturdays. Please let us know all available times that we can schedule services with your family in the box below. The more availability you have, the better we will be able to schedule your child’s services. (required)


BEHAVORIAL CONCERNS:


Please List Current Behavioral Concerns for the Client Below:


Pediatrician Informaion:


Pediatrician Name

Pediatrician Phone

Pediatrician Fax


How did you hear about us? (Check all that apply)
ALP WebsiteFacebookCommunity EventOther

If above is "other", please explain:

If a doctor or friend referred you to us, please tell us who:

 


ALP has as Secure website.

Autism Learning Partners implements a variety of security measures to maintain the safety of any personal information you provide on documents you fill out on our website.

We do not sell, trade, or otherwise transfer your personal information to any outside parties.

Additional Resources

We Come to You - Autism Learning Partners

Did You Know?

Our specialized clinical team comes to assist you! No need to bring your child to an office or clinic,  we’ll travel to meet you in your home, school or community to meet the individual needs of your family.

ASK US HOW

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Help with Insurance

We know how to navigate the health insurance maze. Partner with us and we’ll help you get the Autism coverage you need.

Click Here to View

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Across the Country

We have offices all over the United States to help you with the services  you need.

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