Please fill out our intake form below to ensure timely coordination of services for your child.

If you have any questions, please contact us at (224) 262-6533 or clientrelations@oursaba.com

Child's Full Name

Date of Birth:

Parent or Legal Caretaker's Full Name

Parent's Email

Phone Number:

Street

State/Province

City

Zip Code:

Country

Does your child currently have an autism diagnosis?

Has your child had a Comprehensive Diagnostic Evaluation completed?

If yes, please Provide the Name of the Provider and / or Their Practice That Conducted the Evaluation:

If yes, What Month and Year Was the Evaluation Completed? (Approximate Is OK.)

Who Is Your Insurance Carrier?

Subscriber Name:

Subscriber DOB:

Policy Number:

Group Number:

Photo of Front of Insurance Card

Photo of Back of Insurance Card

Parent's Photo ID

Please upload your child's autism diagnostic report.

How did you hear about us?

Additional Information: