Autism Evaluation, BHT/ABA Form

Providers should use this Autism Evaluation form to refer Alliance members under the age of 21 who may benefit from an autism evaluation and/or behavioral health treatment (BHT), including Applied Behavior Analysis (ABA). Submitting this form initiates the referral process for diagnostic evaluation, ABA/BHT services and determination of service eligibility.

This form must be completed by a physician, pediatrician, neurologist or licensed clinical psychologist (e.g., MD/DO/PhD/PsyD). Information provided in this form will be protected.