Accepted Insurance

Step Beyond Development
Accepted Insurance

Family, integrity, measurable progress, and independence.

(727)-643-7695

Call to schedule a consultation today!

In-Network Accepted Insurances

New Client Intake Form

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Name of Person Completing this form *

First

Last

Name of child *

First

Last

Child's Date of Birth *

MM/DD/YYYY

Phone *

Address *

House/Unit Number, Street, City, Zip Code

Email *

In Need of Translation Services? (Necesita servicios de traducción) If yes, please write primary language (que idioma):

Insurance Provider

CMS, Medicaid, Tricare, BCBS, Aetna, Cigna, United, etc

Child's Insurance Member ID Number *

Referred by (Name)

N/A, MD, Developmental Specialist, Neurologist, Psychologist

Diagnosis

Autism Spectrum Disorder
Oppositional Defiant Disorder
ADHD

Current Behavioral Concerns:

Aggression
Self Injurious Behavior
Property Destruction
Eloping (running out of building, room, vehicle, etc)
Mouthing/PICA
Flopping
Screaming/yelling
Tantrums
Defiance or problems w/ authority
Off Task Behavior
Shutdowns/Withdraw
Vocal Perseveration
Avoidance
Other

Check the unsafe behaviors that you have been experiencing?

My child is experiencing:

Communication Delays
Developmental Delays
Difficulty making friends
Isolated socially
Bullying
Lack of coping skills
Problems at school
Potty training difficulties
Lack of safety awareness
Sensory concerns
Struggles with emotions/non-verbal cues/Social rules-norms
Impulsivity

What delays have you been seeing or skills you'd like more teaching with?

Documentation Required

Comprehensive Diagnostic Evaluation
ABA Referral Letter
Insurance Card

Check the documents that you have?

Any Additional Concerns?

Translation Services

We believe that language should not be a barrier to accessing high-quality care. Step Beyond Development uses Certified Translation Service EKO 4 Traductor Tampa (https://translationsflorida.us) for translation services for our patients who speak languages other than English at no cost to patients. If you would like to take advantage of this no cost translation service, please contact our clinical director, Elya Wambach at 727-643-7695. Para acceder a este servicio gratuito de traducción, póngase en contacto con center director a Elya Wambach Para aceder a este serviço de tradução gratuito, contacte center director: Elya Wambach 要获得这项免费翻译服务，请联系 center director: Elya Wambach center director: Elya Wambach للوصول إلى خدمة الترجمة المجانية هذه ، يرجى الاتصال

Closed Captioning

Step Beyond Development is committed to ensuring our video content is accessible to everyone. As such, all of our videos are hosted through Captioning Star, with a built-in closed captioning feature included. For information on enabling the closed captioning feature, please contact our owner Amanda Sagarian, 727-643-7695.