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Beacon Services Early Intervention Referral Form

For those seeking services for a child under the age of 3 enrolled in Early Intervention services

"*" indicates required fields

Name of person completing form*

First Last

Contact email of person completing form*

Contact phone number of person completing form*

Relationship to Child*

Child's Information

Child's Name*

First Last

Child's Date of Birth*

MM slash DD slash YYYY

DPH number (for service coordinators only)

Child's Gender

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Family’s Primary Language

Is an interpreter required?

Yes

No

Has your child ever received a screening evaluation from Early Intervention?*

Yes

No

Unsure

Has your child ever received a diagnosis of autism from a psychologist or pediatrician before?*

Yes

No

Unsure

Parent/Guardian Information

Parent/Guardian Name*

First Last

Parent/Guardian Phone Number*

Parent/Guardian Address

Same as child's home address

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Email*

Enter Email Confirm Email

May we leave a message at the Parent/Guardian number provided?

Parent/Guardian #2

First Last

Parent/Guardian #2 Phone Number

Parent/Guardian #2 Address

Street Address Address Line 2 City State ZIP Code

Parent/Guardian #2 Email

Enter Email Confirm Email

May we leave a message at the Parent/Guardian #2 number provided?

Contact Information for Early Intervention Coordinator

Early Intervention Coordinator

Please check this box if your Early Intervention Coordinator is unknown

Program*

Service Coordinator*

Phone*

Extension

Email*

Fax Number

Parent Guardian Acknowledgement

By checking this box and signing below, I acknowledge that I am the parent/legal guardian of the child named above and grant Beacon ABA Services the consent to furnish information to and obtain clinical and other needed information from the Early Intervention Provider named above and any of its personnel regarding this referral in order to expedite access to services herein requested.

Parent/Guardian Signature*

Parent/Guardian Name*

Services of Interest

Services of Interest

Please check all that apply

Diagnostic Evaluation from a Licensed Psychologist

ABA Autism Treatment through Early Intervention

ABA Autism Treatment through Insurance - In-Home Services

ABA Autism Treatment through Insurance - Center-Based Services

Not Sure

Insurance

Insurance Carrier

** If your insurance is not listed, we are not in-network with that plan, please contact your insurance for an in-network provider **
Updated 8.2.2023

If Other, Please Specify Your Insurance Carrier

Insurance Member ID

Insurance Group ID

Insurance Phone Number

Image of the front of your insurance card

Accepted file types: pdf, jpg, png, Max. file size: 5 MB.

Image of the back of your insurance card

Accepted file types: pdf, jpg, png, Max. file size: 5 MB.

Secondary Insurance Information, if any

How did you hear about Beacon?*

For other, please specify

Verification

Name

This field is for validation purposes and should be left unchanged.

Corporate Office

300 E Main Street #104
Milford, MA 01757
(508) 478-0207
Directions

Beacon ABA Services specializes in evidence-based treatment to young children

with Autism Spectrum Disorder (ASD).

Programs & Services

Early Childhood Diagnostic Services

In-Home Early Intensive Behavioral Intervention Services

Over the Age of 3 In-Home and Center-Based Applied Behavior Analysis Services

Resources

Patient Resources

Employee Access

Locations

North Andover, MA

North Dartmouth, MA

West Springfield, MA

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