2695 S. Jersey St. Denver, CO 80222 | 303.759.1192 | fax 303.759.1194 | info@fireflyautism.org | www.fireflyautism.org
CLIENT REFERRAL FORM
Date ___________________
Date Recv’d ______________
(Office Use)
Client Full Legal Name (Last, First, MI): _______________________________________________________________
Street Address: ____________________________________________________________________________________
City: _________________________________
State: _________________________ Zip: _____________
Date of Birth: _________________________
Sex: _________
Diagnosis: _______________________________________________________________________________________
Other Relevant Conditions:_______________________________________________________________________
Mother / Legal Guardian: ___________________________________________________________________________
Relationship: (please check)
Biological ______________ Adoptive______________
Step ______________ Foster ______________
Address: _________________________________________________________________________________________
Home Phone (
) _________________ Work Phone: (
) __________________ Cell: (
) _________________
Email: ___________________________________________________________________________________________
Occupation: ________________________________________ Title: ________________________________________
Highest level of education (please circle) High School
9, 10, 11, 12
College
1, 2, 3, 4
Graduate School
Employer: ________________________________________________________________________________________
Employer Address: ________________________________________________________________________________
City: _________________________________
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State: _________________________ Zip: ____________
Father/ Legal Guardian: ____________________________________________________________________________
Relationship: (please check)
Biological ______________ Adoptive______________
Step ______________ Foster ______________
Address: ________________________________________________________________________________________
Home Phone (
) _________________ Work Phone: (
) __________________ Cell: (
) ________________
Email: __________________________________________________________________________________________
Occupation: ________________________________________ Title: _______________________________________
Highest level of education (please circle) High School
College
Graduate School
9, 10, 11, 12
1, 2, 3, 4
Employer: _______________________________________________________________________________________
Employer Street Address: _________________________________________________________________________
City: _________________________________
Parents’ Marital Status: Married _____
State: _________________________ Zip: _____________
Separated _____
Divorced _____
Child lives with (check all that apply) Father _________ Mother __________
Single_____
Widowed _____
other (specify) ___________
CLIENT’S SIBLINGS
Name: ___________________________________________ Age: _______________
Gender: ______________
Name: ___________________________________________ Age: _______________
Gender: ______________
Name: ___________________________________________ Age: _______________
Gender: ______________
Name: ___________________________________________ Age: _______________
Gender: ______________
CLIENT’S PRIMARY CARE PHYSICIAN
Name: _______________________________ Clinic/Company practice: _________________________________
Address: ____________________________________________________________________________________
Phone: (
) _______________________________ Fax: (
) _______________________________________
What agency or individual referred you here for services?
Name: ______________________________
Phone: ______________________
Address: ____________________________________________________________________
____________________________________________________________________
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Program of Interest
Please consider my child for placement in the following programs:
______Home-Based Services (my child could benefit from ABA (applied behavior analysis) therapy in the
Home and community)
______Social Skills (my child could benefit from brief regular social interaction with peers)
______Center/Early Childhood (my child is between 2-6 and needs center-based therapy)
Preferred Schedule: ____ 5 days a week ____ Other: (please describe): ___________
______Center /School Age (my child is between 6-21 and needs center-based therapy.)*
*Pending authorization by the child’s school district
______ Additional Services:
_____ Speech Therapy
_____ Occupational Therapy
_____ Physical Therapy
_____ Mental Health Therapy/Counseling
_____ Psychiatric Services
______Other (please explain): ____________________________________________
Insurance and/or Funding
Information
List which insurance plan you have:
NOTE: client would need to call and request they send a referral to Firefly Autism
Name of Company
Plan #:
Phone number for customer service:
Copay:
Group #:
Plan renewal date:
Card Holder’s Information
Name:
Relationship to client:
__Male __Female
Social Security Number:
Name of Medicaid program:
Date of Birth
Name of Employer:
Medicaid Information
Child’s Medicaid number:
Y N We have applied for a waiver (circle which: CWA CES
Y N We are on a waiting list for a waiver (circle which: CWA
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Other:
CES Other:
Family Support Questionnaire
Y N
Y N
Y N
Y N
Y
Y
Y
Y
Y
N
N
N
N
N
We are in contact with our community centered board (CCB)
(if yes, list any contact name you’d like to share and name of the CCB): _______________
We have family or others who would be willing to be trained as respite providers
We have enough family support
We have mental health needs
(if yes, please explain): _______________
We would like support finding siblings programs or support
We need help finding financial assistance
We need help finding educational advocates
We would like to help other families
We would like to receive parent training or family education
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Notice to Families Funded through HIMAT
If you are funded by a Colorado health insurer under the Health Insurance Mandated Autism
treatment (HIMAT) law, your Consultant/BCBA will create a service plan outlining a plan for the usage
of your child’s funding through Firefly services. Beyond the creation of that document, it is your
responsibility to track your child’s funding and expenditures.
Our rates are as follows:


Hourly BCBA/Consultant - $110.00/hour
Hourly Senior Therapist and Home Team - $45.00/hour
If you are unsure of how much funding is available for your child within your insurance plan year,
please contact your insurance provider to obtain that information.
Before any services can start with Firefly, authorization must be provided in writing from your health
insurer. Please contact your insurer to find out if you are eligible for the HIMAT funding. Be specific in
asking whether or not your insurer will cover ABA Therapy (Applied Behavior Analysis).
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THERAPY INFORMATION
Please list client’s current therapies and/or other treatment professionals:
Date started: ____________________________________
Type of services: _________________________________________________________________________________
Service provider: _________________________________________________________________________________
Contact Information: ______________________________________________________________________________
Date started: ____________________________________
Type of services: _________________________________________________________________________________
Service provider: _________________________________________________________________________________
Contact Information: ______________________________________________________________________________
Date started: ____________________________________
Type of services: _________________________________________________________________________________
Service provider: _________________________________________________________________________________
Contact Information: ______________________________________________________________________________
Date started: ____________________________________
Type of services: _________________________________________________________________________________
Service provider: _________________________________________________________________________________
Contact Information: ______________________________________________________________________________
Complete this section if your child attends a school, center, preschool, etc.
Current Facility and Address:
Grade Level if school: ______________________________________________________________________________
Date Enrolled:
Contact Information:
Y N Child has an IEP (If child has an IEP, a recent copy should be submitted with this packet or as soon as possible)
Y N Child has IFSP (If child has an IFSP, a recent copy should be submitted with this packet or as soon as possible)
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EDUCATIONAL PROFILE
Please indicate schools attended in chronological order.
School Name and Level
Date Attended
Has your child ever received special education services? Please explain
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Describe any current school programs.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Has your child ever received any developmental evaluation or testing in the past?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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FIREFLY AUTISM PROGRAM
DESCTIPTIONS
Overview
One of a handful of autism centers in Colorado, Firefly offers some of the
most comprehensive services, including clinical assessments for the development of individual treatment plans, an intensive
early intervention program, two school-age programs, a home and community based program, including services on the
Western Slope, and social skills classes. Firefly serves children ages 18 months to 21 years, and every program has a 1:1
student to teacher ratio. Firefly’s treatment is based on leading, empirically based interventions, including use of Applied
Behavior Analysis to teach skills. The supervising personnel for ABA-based programs are Board Certified Behavior
Analysts (BCBA’s) who, in addition to holding a graduate degree, completing a series of coursework in ABA, and required
hours of supervision, are credentialed by the Behavior Analysis Certification Board (www. BACB.com). To maintain
certification, each analyst must maintain continuing education at least annually. To enhance service delivery, our organ
includes speech and occupational therapy, mental health coalescing and psychiatric services, based on the individuals needs
Early Childhood
Firefly’s Early Childhood Program serves children 18 months to 6 years old and uses ABA (Applied Behavior Analysis) to
assist each child in maximizing their learning potential. The program uses naturalistic teaching within daily routines to
establish, maintain, and increase the children’s active engagement with people and their surroundings. Individual strengths
and needs are identified across all developmental areas including social, language, cognition, motor, and play skills.
Progress is assessed daily through graphing and data analysis with a review and revision of goals every 12 weeks. A
primary focus of the program is functional communication and language. Services emphasize teaching the child to
demonstrate the same developmental level as their neuro-typical peers. Therapy includes 1:1 teaching and training by
highly motivated and trained staff
School Age Program
Our School Age Programs are for children 6 to 21 years old, with our Primary Program serving children six to 13 and our
Secondary Program serving individuals 14 to 21. Our specialized programs identify each student’s individualized strengths
and needs across multiple developmental areas including social, emotional, behavioral, language/communication,
academics, and adaptive/life skills. Individual goals are created from the strength and needs assessment. Each goal
includes multiple learning objects which are targeted daily. Progress on the objectives is assessed regularly. Children are
taught how to learn from peers, how to work cooperatively with peers and how to find more adaptive ways to communicate.
Services focus on skill acquisition and reduction of problem behavior. This program places an emphasis on teaching
functional skills. This innovative program, funded primarily by school system, includes 1:1 instruction by highly motivated
and trained staff.
Home-Based Services
Firefly’s home and community based program treats children ages 18 months to 21 years throughout the Front Range and
out of our Western Slope office in Grand Junction. A parent engagement model is employed as parent involvement is a
large component of any child’s program and is essential for the ongoing success of your child. By providing the parents of
children with autism specialized competence in how to promote their child’s learning, more intervention time becomes
available to the child and more normalized family functioning becomes a long-term reality. This program invoices
wraparound services to treat the entire individual, wherever the need arises; in the home, in the school, and in the
community. Individuals are served by highly qualified and motivated Board Certified Behavior Analysts as well as
Registered Behavior Technicians. Services emphasize community integration.
Social Skills Group
Firefly’s Social Skills Groups are developed to meet the social and emotional needs of children with Autism Spectrum
Disorder. We help group members effectively express feelings, communicate with others, and develop and maintain
friendships in a positive, comfortable environment. We believe that our approach, coupled with strong group dynamics will
help group members feel confident in their abilities to make friends within the group, as well as outside of the group
setting. We offer opportunities to promote generalization of skills through our weekly “challenges” to be completed at
home, such as appropriately calling or even texting a friend. By providing structured training in social skills, in a group
setting, each child can learn needed skills to more fully participate in social interactions similar to their neuro-typical peers.
Groups meet three times a week, including weekends and after school.
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