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Autism Referral

An autism diagnosis is required for ABA services. Services will not start until a diagnostic report or verification is provided. Please attach ABA documentation and a copy of insurance card, if applicable, in upload section below.

Autism Services Referral Form

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Client Name(Required)
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Client Address(Required)
Parent/Guardian Name (Required for clients under the age of 18)(Required)
Providing an email address, if available, helps us connect you to needed services as efficiently as possible.
Current Tanager Place client?(Required)
Date of Diagnosis

Recommended/Requested Services

Autism Services
Please include information about current symptoms, behaviors, functioning and trauma. Do these occur in the home, school, community, or across all settings?

Primary Insurance

Insurance verification is required before appointment. While insurance information is not required as part of this form, providing it now will expedite the path to treatment.
Name on Insurance Card

Secondary Insurance (if applicable)

Name on Insurance Card
Drop files here or
Accepted file types: jpg, pdf, png, gif, Max. file size: 256 MB.

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