Lakewood Basic Information Form Parent/ Guardian's Name* First Last Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Primary Policy Holder* First Last Birthday of Primary Policy Holder* MM slash DD slash YYYY Client Name* First Last Client DOB* MM slash DD slash YYYY Client Social Security Number Patient Diagnoses Code* How did you hear about Connect Plus? We would personally like to thank them.* Insurance Plan* Upload a copy of the front and back of your insurance card* Drop files here or Select files Max. file size: 256 MB. *We participate with most insurance plans. We are not yet partnered with medicaid.Do you have a Secondary Insurance Policy?*YesNoSecondary Insurance Plan Upload a copy of the front and back of your secondary insurance card Drop files here or Select files Max. file size: 256 MB. I acknowledge that Connect Plus Therapy might not be in-network with my insurance plan and hereby authorize Connect Plus Therapy to check eligibility for ABA benefits:* Parent/ Guardian signature that the above information is true.* Reset signature Signature locked. Reset to sign again