Advanced Therapy Associates
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Client Information
Client Name
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Phone Number
Date of Birth
Race
Insurance Provider
Insurance Number
Parent/ Guardian Name
Referral Information
Referral Source Name
Referral Source Contact Number
Services Requested
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ADHD testing
Intelligence Testing
Developmental/ Autism Testing
Maternal and Infant Health
Behavioral Health Assessment
Counseling
Case Management
ADvantage Program Assistance
Rehabilitation
Presurgical Evaluation
Reason for Referral
Name of Requested Provider (If you have one you would like to use)
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