Therapy Interest Form

Insurance

Oregon Autism Center LLC does not bill insurance directly and Dr. Lundeberg is not an insurance provider. Statement are provided (superbills) that can be submitted by you to your insurance company for reimbursement based on your out-of-network benefits. Please contact your insurance company regarding any out-of-network benefits questions.

Identified Client's Name

Identified Client's Date of Birth

Identified Client's Gender Identify & Pronouns

Person Completing Form (Include Relationship to Proposed Client)

Is the Identified Client Their Own Legal Guardian?

Yes No

If NO, Who is Client's Legal Guardian?

Contact Email Address

Contact Phone Number

Does the identified client have Oregon Health Plan (OHP) insurance coverage? If so, please be aware legal regulations may limit your access to Oregon Autism Evaluations LLC services as Dr. Lundeberg is not an insurance provider.

Yes No

What are you looking for in therapy? What are your therapy goals?

Has prospective client previously been diagnosed with any psychological conditions? If YES, what conditions? Does prospecitve client suspect they have any undiagnosed psychological conditions?

Any other information that you want to share with us regarding your pursing therapy with Dr. Lundeberg?

Oregon Autism Evaluations LLC does not accept or bill insurance.

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