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Client Referral – Adapt for Life

Date of Referral(Required)

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Client Name(Required)

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Date of Birth(Required)

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Phone # 1(Required)

Social Security #(Required)

Own Legal Guardian?(Required)

Yes

No

Primary Diagnosis(Required)

Secondary Diagnosis(Required)

Does individual need to be assessed for Autism Diagnosis?(Required)

Yes

No

Primary Caregiver(Required)

Relationship with Primary Caregiver(Required)

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If Waiver Services, please get Case Manager Name, Number and E-mail(Required)

If DOE, please get Contact Name, Number and School District(Required)

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ID #(Required)

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List Significant Behaviors(Required)

Communication Needs(Required)

Toileting Needs(Required)

Primary Care Physician(Required)

Primary Care Physician Phone Number(Required)

Psychiatrist who confirmed Autism Diagnosis (insurance only)(Required)

Medications Administration Needed(Required)

Yes

No

List of Medications(Required)

Risks

Seizures

Dysphagia

Swallowing/Chewing/Dining

Constipation

GERD

Dehydration

Ambulatory Needs(Required)

Special Diet(Required)

Yes

No

If yes, explain(Required)

Our Services

What We Offer
Clinic-Based Autism Therapy
Autism Diagnostic Services
Speech Therapy
Home & Community-Based ABA Therapy

Journals

Your Child Was Just Diagnosed with Autism: What to Do in the First 90 DaysOctober 13, 2026
Speech-Language Therapy for Children with Autism: What an SLP Assesses and How Goals Are ChosenOctober 6, 2026
How ABA Therapy in Lexington KY Supports Children with Autism: What Local Families Should KnowSeptember 29, 2026
What Is Applied Behavior Analysis? What Indianapolis Families Should Know Before Starting TherapySeptember 21, 2026
How ABA Therapy in Orland Park Builds Real-Life Skills in Children with AutismSeptember 15, 2026