Telehealth Services - EAS

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Telehealth Eligibility Form

Central Reach ID*
Client Insurance Payor
BCBA Name*
Location*
Would you be willing to participate in remote services?*
- Yes
- No
Do you have a reliable internet connection in your home?*
- Yes
- No
Do you have an electronic device with a camera that could be used?*
- Yes
- No
Is your WIFI private and password protected?*
- Yes
- No
Do you have a private, quiet space to provide services remotely?*
- Yes
- No

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Resources for Parents