Admission Form

APPLY FOR ADMISSION

With innovative therapy and compassionate care, we’ll help you find balance…for family, for community, for life.

Before starting the application, it will be helpful to have the following documents ready to upload. (This information may also be forwarded to us at a later time).

· A psychological evaluation stating an autism spectrum diagnosis (conducted by a licensed psychologist or developmental pediatrician)

· The most recent interdisciplinary team annual review (IEP, ISP, IPP, etc)

· SIS (Supports Intensity Score) Evaluation (adults only)

· Medicaid and/or insurance information

Applicant Information

Applicant First Name

Applicant Last Name

Is the applicant currently receiving any services from Balance Autism?

YesNo

Current Services Received

Services

Location

Gender

Date of Birth

MM/DD/YYYY or MM-DD-YYYY

Age


Applicant Address	Street State City Zipcode

Referral Information

What is your relationship to the applicant?

Relationship to Applicant - Other

Your First Name

Your Last Name

Phone

Email

How did you hear about us?

Other - Referral Name

Name of School

Name of Community

Name of Psychologist/Psychiatrist

Name of Case Manager

Name of Physician

Name of Family Navigator

Are you the legal guardian?

YesNo

Is your address same as applicant?

YesNo

Guardian Information

Guardian's First Name

Guardian's Last Name

Guardian's Primary Phone Number

Guardian Email


Guardian Address	Street State City Zipcode

Guardian Address

Street

City

State

Zipcode

Guardian's relationship with applicant?

Guardian Relationship - Other

Preferred Language of Communication

Other - Preferred Language of Communication

Is there a second guardian?

Guardian 2

Guardian's First Name

Guardian's Last Name

Guardian's Primary Phone Number

Guardian Email


Guardian Address	Street State City Zipcode

Guardian's relationship with applicant?

Guardian Relationship - Other

Preferred Language of Communication

Other - Preferred Language of Communication

Would you like to receive text alerts

Medical Information

Medical Information

List all diagnoses.
Applicant must have a diagnosis of autism spectrum disorder to receive services from Balance Autism.

	Yes	No
Does the applicant have any physical limitations?

Please describe the physical limitations.

If the applicant has any physical limitations, please list any adaptive devices (i.e. wheelchair, shoe inserts, braces, walkers, etc.)

	Yes	No
Has the applicant had any seizures?

Please provide a brief description of the type, frequency and severity.

	Yes	No
Does the applicant take any prescription medication?

Prescription Medication

Medication

Frequency

Dosage

	Yes	No
Does the applicant have any allergies?

Allergy Information

Type of Allergy

Reaction

How does the applicant communicate?
Select all that apply

Please hold the CTRL key to select multiple values from this list.

Other - How does the applicant communicate?

Where does the applicant need the most support?

Please limit your selection to 5 of the applicant's most important support areas

Please hold the CTRL key to select multiple values from this list.

Other - Area Applicant Needs Most Support

Applicant Insurance Information

Primary Insurance

Policy Holder's Date of Birth

MM/DD/YYYY or MM-DD-YYYY

Policy Holder's First Name

Policy Holder's Last Name

Policy Holder's Relation to Applicant

Other Relation - Please Specify

Other - Primary Insurance

Is the applicant currently covered by any other insurance?

Secondary Insurance

Policy Holder's Date of Birth

Policy Holder's First Name

Policy Holder's Last Name

Policy Holder's Relation to Applicant

Other Relation - Please Specify

Other - Secondary Insurance

Medicaid Number/ Title 19 Number

Does the applicant have a case manager?

YesNo

Case Manager Information

First Name

Last Name

Phone Number

Email

Case Manager Additional Information

County of Financial Responsibility

Approved Medicaid Funding

Other - Approved Medicaid Funding

Has the applicant applied or has been approved for funding through the Iowa Autism Support Program (ASP) funding?

Attachments

The following items are needed to complete the applicant's file. This application might be submitted without supporting documentation. However, all remaining items must be received before an applicant will be added to our waiting list.

Attachments

Please upload the applicant's psychological evaluation.
This evaluation must be conducted by a licensed psychologist or developmental pediatrician to determine a diagnosis on the autism spectrum. If you're applying for ABA services, it's incredibly important this documentation identifies which autism-specific assessment too was used, as well as the scores obtained, to determine the diagnosis. This requirement is needed in order for Balance Autism to obtain necessary authorization to provide services to this individual in the future.

Please upload the applicant's Individual Service Plan, if applicable.
The most recent interdisciplinary team plan might be an IEP, ISP, IPP, IFSP, etc.

Please upload Primary Insurance Information
A copy or picture of the insurance card. If you have insurance that is not Medicaid, please attach pictures of both sides of the card.

Please upload Secondary Insurance Information.
Please send a copy or picture of the insurance card. If you have insurance that is not Medicaid, please attach pictures of both sides of the card.

Please upload Support Intensity Score Evaluation if available.

Please upload a valid Case Management Release of Information.

Please upload the release of information document signed by the guardian which authorizes communication between case manager and Balance Autism.

Additional Documentation 1

If you would like to provide any additional information, please add it here.

Please select the type of other additional documentation you would like to provide.

Admission Form

Services

Medical Information

AttachmentsThe following items are needed to complete the applicant's file. This application might be submitted without supporting documentation. However, all remaining items must be received before an applicant will be added to our waiting list.

Attachments

The following items are needed to complete the applicant's file. This application might be submitted without supporting documentation. However, all remaining items must be received before an applicant will be added to our waiting list.