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Request Services

Request Services

Use this page to request services by either selecting the Initial Referral Form or the Application for ABA Services Form below.

Select Your Preference Below
Community Services Referral
Enter N/A if unknown.
(Texts will only be sent to Mobile Phone number entered above. Emails will only be sent to Client Email listed above.)
Application for ABA Services

Instructions:

Please complete the following information and submit online. You can also download this form from our website, fill out on your computer and print, scan and email to wufoo@npsga.com, or print and fax to 919-896-6443.


Date:

Referred By: (required)


Referral Agency Number: (required)


Client Information:


Last Name, First Name Middle Initial:
,

Email Address:

DOB:

Home Address

,

Sex:
MF

Race: (Optional)

SSN:

County:




Contact Information:


Parent or Legal Guardian Contact 1:(required)

Name: Relationship to Client:

Mobile Phone: Home Phone:

Email Address:

Address (if different from client):



,

Primary Language:


Parent or Legal Guardian Contact 2:

Name: Relationship to Client:

Mobile Phone: Home Phone:

Email Address:

Address (if different from client):


,

Primary Language


Insurance Information:


Primary:

Company / Type:
/

Policy Holder Name: DOB:

Subscriber ID: Effective Date:


Secondary:

Company / Type:
/

Policy Holder Name: DOB:

Subscriber ID: Effective Date:


Reason for Referral/Primary Concerns about the Client:


During the intake process we will be requesting detailed information regarding your child’s history, current needs, and caregiver concerns. Please identify your top three concerns that you would like addressed during the first 6 months of treatment.

1.

2.

3.

You will be hearing from us within 72 hours. At that time a member of Northstar Psychological Services will be requesting a copy of a signed diagnostic or psychological evaluation confirming a diagnosis of Autism Spectrum Disorder(F84.0).

Select Your Preferred Location: