Mindful Mentality LLC | SimplePractice

Your info

First name

Last name

Phone

State

Select the state you live in

Child's Name

Child's Date of Birth

Respondent's Relationship to Child

What level of ASD was your child diagnosed with?

When was your child diagnosed? (approximate date is fine)

Who diagnosed your child's ASD? Please list the provider's name and type of provider (developmental pediatrician, psychologist, etc.)

Child's Gender

Administrative

Referral source

Enter how you were referred to our services

Does your child already have a prescription or referral for ABA services?

Tricare Only: Is your child already enrolled in EFMP?

On a Scale of 1-5 How Familiar Are You With ABA?

1 2 3 4 5

As our clinic grows, we are preparing to offer additional therapies and services. Please select any additional services below that you would like more information on when we begin to provide this service?

OT SPEECH MENTAL HEALTH

Is there any additional information that we should know about the child or the family?

Limited to 600 characters

Billing & Payment

Insurance details

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.