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Referral Form



  • Thank you for inquiring about services with Achieving True Self! Please complete this form to the best of your ability. If you prefer to speak to someone by phone who can support you in making this inquiry, please call 1-866-287-2036 and select "Consumer Services." If we are able to accept your referral, a team member will be in contact with you to discuss our next steps.

  • Client First Name:

  • Client Last Name:

  • If you are the custodial parent or legal guardian of the potential client being referred, please share their first and last name. If you are making a referral on someone's behalf and do not have a release on file to provide the client first and last name, or if you are the non-custodial parent or a family member, you may use initials instead. At least the potential client's initials are required for tracking purposes.

  • Gender:




  • Date of Birth:

  • Gender:




  • Parent or Caregiver First Name (If Applicable; Required for ABA, IBHS, PCIT, or Speech Referrals):

  • Parent or Caregiver Last Name (If Applicable; Required for ABA, IBHS, PCIT, or Speech Referrals):

  • Parent or Caregiver DOB (If Applicable; Required for ABA, IBHS, PCIT, or Speech Referrals):

  • Address: *
    		City: *
    County: *
    		State: *
    		ZIP: *

  • Phone:
    		Contact Preference:
    E-mail:

  • Are We Permitted to Contact You By Text Message?: *



  • What time of day may we contact you?:

  • Please List Languages Spoken at Home: *

  • How Were You Referred To ATS?:

  • What Services Are You Interested In?:











  • Are You Currently Receiving Any Services?:















  • Month of Evaluation or Written Order (If Applicable; Required for ABA, IBHS, PCIT, Occupational Therapy, or Speech Therapy Referrals)::

  • Year of Evaluation or Written Order:

  • Please list all days and times that you are available to participate in our services. Services range in intensity and frequency.

  • Days Available:








  • Times Available:




  • As specifically as possible, please list the timeframes of availability for morning, afternoon, and/or evening:

  • Please list any days and times that you are NOT available below in the next section.

  • Limitations to Scheduling: *

  • Do you have any limitations or preferences with staffing (for example, male vs.female)?:

  • Do you or any family members have any allergies that we should be aware of?:

  • Do you have any pets?:

  • Insurance Type (please note if your plan is through Medicaid):

  • Insurance ID (and Group Number, if applicable):

  • Name and DOB of Policyholder (if commercial coverage):

  • Are there any formal custody agreements in place?:



  • Is there guardianship in place?:



  • If this is an ABA, IBHS, Center-Based, PCIT, Speech Therapy, or Occupational Therapy referral, please upload the following as part of your referral request: a copy of the front and the back of your insurance card(s), a copy of your most recent diagnostic evaluation and/or *written order (*PA residents only) that documents the diagnosis and recommends services, and any other documents that would be helpful for us to review (a speech therapy evaluation, a school IEP, etc.)

  • Documentation:
    (Acceptable Formats: .pdf, .doc, .docx, .jpg, .jpeg)


* = Required

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