Start Services Client Intake Form Ready to Start ABA therapy with Applied Behavior Strategies? Client Name * (Childs Name) First Name Last Name Date of Birth * MM DD YYYY Gender Male Female Primary Language Client Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Primary Contact Phone * (###) ### #### Email * Preferred Method of Communication * Phone Email Text Message Parent/Guardian Information Name * First Name Last Name Relationship to Client * Phone * (###) ### #### Email * Emergency Contact Information Name * First Name Last Name Relationship to Client * Phone * (###) ### #### Insurance Information Insurance Provider * Policy Holder's Name First Name Last Name Date of Birth (Policyholder) MM DD YYYY Policy Number Group ID Secondary Insurance Secondary Insurance Provider Policy Holder's Name First Name Last Name Date of Birth (Policyholder) MM DD YYYY Policy Number Group ID Medical History Primary Physician Name Primary Physician Phone Number Current Medications and Dosage Allergies (If Any) Previous ABA Therpy? Yes No Details for Previous ABA Therapy Other Treatments Speech, Occupational Therapy, etc. Behavioral and Developmental Information Reason for Seeking ABA Services Areas of Concern e.g., communication, social skills, behavior challenges, etc. Goals and Expectations What are your primary goals for ABA therapy? e.g. improve communication skills, decrease challenging behaviors, etc. Diagnosis Current ASD diagnosis Yes No Thank you! We will be in touch soon.
