Straith Behavioral Health - Request for Information

Request Information:

Parent/Guardian Full Name

Phone Number

Address

City

State

Zip Code

Name of Child Needing Services

Child’s Date of Birth

Insurance Type

Upload Insurance Cards

Upload all of the following you have: Autism Evaluation, Psychological Evaluation, Doctor Recommendation for ABA Services, Past ABA Service Discharge Statements, Medication List

Do you have a secondary insurance (If yes, please specify)

Does the individual receiving services have an autism diagnosis? (If yes, please upload below)

If the individual does not have an autism diagnosis, are you currently seeking a diagnosis from a diagnosing provider?

Parent Training Sessions are required for all of our programs between the hours of 9AM-4PM. Are you able to attend in person meetings at Straith?

Has your child ever received ABA therapy?

Does your child have any of the following behaviors that concern you? Check all that apply.