We thank you for considering Meaningful Outcomes as your services provider. We know you have many options to choose from and look forward to getting started on this journey.

- Alicia Morgan-Nelson, CEO

Step 1:

Prospective clients must submit a doctor's order with the child's diagnosis and a recommendation for ABA, HBTS or PASS therapuetic services. Client must also fill out a basic demographics form, insurance information, and include concerns and availability.

Step II:

Receive authorization to begin an initial assessment and meet with the family and child to complete an intake assessment. The intake assessment will review the child's medical, psychological, and behavior history. The initial intake meeting is an interview format to collect all needed information.

Person Making Referral

Name

First Name

Last Name

Organization

Phone

Country

(###)

###

####

If referral is being made by someone other than the parent

Parent Name

First Name

Last Name

Parent Email

Parent Phone

(###)

###

####

Primary Language

Best time(s) to contact

Best Method of Contact

Phone

Test

Client Information

Client Name

First Name

Last Name

DOB

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Diagnosis

Do you have?

Diagnostic Evaluation by MD or licensed individual OR Letter of medical necessity on MD or licensed individual letterhead stating: • Client's name • Client's diagnosis with applicable codes • Due to those diagnoses, they are making a referral for home based therapeutic services and that these services are medically necessary and recommended for the child and family at this time.

Yes

In Process of getting

Insurance Coverage

Primary Insurance Coverage

Other (if not listed above):

Secondary Insurance Coverage?

YES

Concerns and Availability for Services

The more we know, the more we can better assist.

Referral Form (Copy)