Insurance Application

TDLC - Confidential Insurance Client Intake Form

General Information
Gender: Male | Female
Patient (child's) Name
Child's Date of Birth
Street Address
City, State, Zip
Home Phone
E-Mail
Parent's Name
Parent's Phone
Insured's Name
Policy Holder Date of Birth
Check the services you require:
ABA Services | Social Skills | Speech Therapy | Parent Training | Counseling Services | Occupational Therapy
Diagnosis - VERY IMPORTANT! - Check all that apply
Autism Spectrum Disorder | PDD-NOS | Seizure Disorder
Encephalopathy | Speech Delay | Receptive/Expressive Language Disorder
Other Disorders
Primary Doctor/Physician's Name Phone Number
I agree to provide medical release form. (Download Form Here)
Insurance Information
Insurance Company
Policy Number
Insurance Address/P.O.
Insurance City, State, Zip
Insurance Phone Number
Policyholder Name
Relationship to Patient
Group Name / Number
Medicaid Information
Type of Medicaid
Medicaid ID Number
Type Full Name Date
  
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By pressing the "submit form" button above, I acknowledge that all information is true to the best of my knowledge

Company Announcements

Recent Blog Posts

  • ABA In-Depth: Behavior Analysis and Learning
    Hello, TDLC family! I know that many of you read and enjoyed our 4-part blog series on the basics of ABA, found here. Over the course of the next few blogs, we’re going to take those basic i
    0 comment(s) · 842 hits · Read More
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    9 votes
    posted by Jessica Wooden on Wednesday, 02 November 2011
  • ABA Basics, Part 4: Negative Punishment and Extinction
    The time has come to wrap up our 4-part blog series! As I mentioned in our first blog, the goal of this series is to explain the basic tenets of Behavior Analysis: Reinforcement (Positive and Negative
    0 comment(s) · 1033 hits · Read More
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    8 votes
    posted by Jessica Wooden on Thursday, 08 September 2011
  • ABA Basics, Part 3: Positive Punishment
    In the last two parts of this blog series we looked at reinforcement, which increases a certain behavior. Today we are going to explore positive punishment, which has the effect of decreasing a behavi
    0 comment(s) · 906 hits · Read More
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    12 votes
    posted by Jessica Wooden on Wednesday, 31 August 2011

Recommended Resources

Feat Houston

www.feathouston.org - Families for Effective Autism Treatment – a non-profit organization in Houston that provides information on autism, ABA treatment and support groups in the Houston and Texas area.

 
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