APPLICANT INFORMATIONName: DOB: Diagnosis: Autism Spectrum DisorderOther: (Include Diagnosis)Age: List of all current medications and dosage Current address: Mobile number: Has patient ever received ABA services? YesNoPrimary Care Physician: Other current interventions: SpeechPTOTPersonalizedCAREGIVER INFORMATIONName of Caregiver 1 / Parent: Relationship to patient: Mobile number: Email: Name of Caregiver 2 / Parent: Relationship to patient: Mobile number: Email: Primary home address of patient: Preferred method of communication: EmailPhoneOTText chat/ iMessage (number which is preferred):PRIMARY AREAS OF CONCERNMajor areas of focus for the patient: Challenging behavior of concern for the patient: Does the patient have health insurance? YesNoPrimary Insurance Provider: Primary home address of patient: Secondary Insurance Provider: How did you hear about Blooming Horizons LLC?