Name: South Shore Autism Center
Address: 45 Pond St, Norwell, MA, 02061, US
Telephone: (781) 421-6182
Price range: $$

Please note: If you need translation services to complete the form, please call (781) 421-6182 ext 218 for assistance.

Initial Client and Insurance Information Form
(Fields marked with * are required.)

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This field is for validation purposes and should be left unchanged.
Personal Information
Child Name*
First Last
Gender*
- Male
- Female
- Other
Date of Birth*
MM slash DD slash YYYY

*Please note that counseling services are available for children ages 6 and above.
Name of School*
Grade in School*
Diagnosis (If any)*
Privacy Notice: The information you provide will be kept confidential and used only to respond to your inquiry and determine how we may be able to help your child. Please do not include detailed medical information beyond what is necessary for us to contact you and discuss services. Submission of this form does not establish a provider-client relationship.
Does your child have an IEP or 504 and are you willing to share this with us?*
Other Personal Information
Parent/Guardian Name*
First Last
Occupation*
Phone 1*
Phone 2
Email*
Address*
Street Address Address Line 2 City State ZIP Code
2nd Parent/Guardian's name
First Last
Occupation
Phone (home)
Phone (mobile)
Email
Address (if different from above)
Street Address Address Line 2 City State ZIP Code
Referral Information
How did you hear about us?*
If you are referred by a doctor, school or other provider, please let us know which one.
Primary Health Insurance Information
Subscriber's Name*
Subscriber's date of birth*
MM slash DD slash YYYY
Insurance Company*
Identification Number*
Group Number
Authorize release of Information*
- I authorize release of information and benefits assignment from my insurance company.
Parent E-Signature*
Date*
MM slash DD slash YYYY
In your own words, describe your reasons for inquiring about our counseling services:*
Language and Communication Preferences
What language(s) (if any) other than English is/are spoken in your home?
Would you like an interpreter to review written communication?*
- Yes
- No
If yes, please list the language(s) you would like us to use.
Signature*
By entering your name above you agree to receive information and services from South Shore Autism Center.

Intake Form – Child & Teen Counseling Services

Personal Information

Other Personal Information

Referral Information

Primary Health Insurance Information

Language and Communication Preferences

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