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

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

Yes

Unsure

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

Yes

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

Services of Interest

Please check all that apply

Behavioral Consultation while waiting for diagnostic assessment

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

Consultation Areas of Focus

A. Communication

Not concerned

Somewhat concerned

Very Concerned

How does your child communicate?

Uses words to communicate their needs and wants

Uses signs or gestures to tell us what they want

Is not using words now

Will label things they see

Will point to what they want

May cry or tantrum to get what they want

What are your concerns around communication?

B. Problem Behaviors

Not concerned

Somewhat concerned

Very Concerned

What problem behaviors interfere with your family life?

Tantrums

Aggression

Repetitive behaviors

Refusal to do things you know they can do

What are your concerns around problem behaviors?

C. Self-Care

Not concerned

Somewhat concerned

Very Concerned

What problems do you have during self care routines?

Refusal/difficulty with dressing or undressing

Limited food intake/variety of foods

Resistance to brush teeth

Difficulty with bath time/hair washing

What are you concerns around self-care routines?

D. Community Behaviors

Not concerned

Somewhat concerned

Very Concerned

What problems are you experiencing with your child in the community?

Refusal to stay with you when walking

Refusal to sit in the restaurant

Cry or tantrum in a store

Refusal to share at the playground

What concerns do you have with community behaviors?

E. Sibling Interactions

Not concerned

Somewhat concerned

Very Concerned

What problems are you experiencing with your child’s interactions with siblings?

Aggression toward siblings

Refusal to play with siblings

Inappropriate play with siblings

What concerns do you have with sibling interactions?

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

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).

Beacon Services Early Intervention Referral Form

Child's Information

Parent/Guardian Information

Contact Information for Early Intervention Coordinator

Services of Interest

Consultation Areas of Focus

Insurance

Corporate Office

Programs & Services

Resources

Employee Access

Locations