New Client Intake Form

New Client Intake Form

Please complete this registration form
Parent Full Name*

First NameLast Name
Phone*

Area CodePhone Number
E-mail*
Child's Name

First NameLast Name
Child's Date of Birth
Address*

Street Address

Street Address Line 2

CityState / Province

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

YesNo
Child's Diagnosis*

AutismDown SyndromeLearning DisabilityOther
Insurance*

Tricare WestCignaPrivate PayMolinaAetnaOther
Type of ABA therapy needed*

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

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

Yes (if "yes" please select the behavior)NoHead bangingHand or arm bittingHair pullingEye gougingFace or head slapping or punchingSkin pickingScratching or pinchingOther
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*

InsuranceDoctor's referralSearch engine
Preferred method of contact*

PhoneEmail
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