New Client Intake Form

New Client Intake Form

Please complete this registration form
Parent Full Name *

First Name Last Name
Phone *

Area Code Phone Number
E-mail *
Child's Name

First Name Last Name
Child's Date of Birth
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Has the child been diagnosed by a doctor? *

Yes No
Child's Diagnosis *

Autism Down Syndrome Learning Disability
Insurance *

Tricare West Cigna Private Pay Molina Aetna
Type of ABA therapy needed *

In-Home Telehealth
Availability for therapy (choose one or more) *

Morning Afternoon Evening (only available to Telehealth clients)
Does the child engage in Self-Injurious Behaviors (SIB)? *

Yes (if "yes" please select the behavior) No Head banging Hand or arm bitting Hair pulling Eye gouging Face or head slapping or punching Skin picking Scratching or pinching
Is the child currently in therapy? (e.g ABA, Speech Therapy, Occupational Therapy) *
Brief description about the child's problematic behaviors *
How did you hear about us *

Insurance Doctor's referral Search engine
Preferred method of contact *

Phone Email
Should be Empty:

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