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  • Intake Questionnaire ABA Therapy

    -CONFIDENTIAL-
  • Please complete this Intake Form regarding your child.  Progressive Option Support Services views all the information that you provide us with as strictly confidential on this HIPAA compliant submission platform.  This information is helpful for us in developing an initial understanding of your child’s needs and provides critical information for us to discuss with your insurance company to get authorization for services.

    Please upload front and back copies of your insurance card, a copy of the autism evaluation report, and/or a copy of the doctor’s script with ASD diagnosis. 

     

    A MEMBER OF OUR STAFF WILL CONTACT YOU WITHIN 24HRS


  • General Information

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  • Insurance Information

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  • The mandatory fields have been requested.  You may continue with the intake form but please remember to upload front and back copies of your insurance card, a copy of the autism evaluation report and/or a copy of the doctor’s script with the ASD diagnosis.

  • Medical Information (Optional)

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  • Please also provide the following:

  • If yes, please provide the following information:

  • If yes, please provide the following information:

  • Please note that the diagnosis information is required for insurance coverage. By having this information, it assists us when speaking with your insurance company to get authorization for services and providing you with invoices for reimbursement through insurance.

  • Current/Previous Therapy Provider (Optional)

  • Please provide us with information regarding the following types of current or previous therapy providers and copies of any recent evaluations that indicate dates of previous treatment and therapeutic interventions and responses.

  • If yes, please provide information below:

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  • If yes, please provide information below:

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  • If yes, please provide information below:

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  • If yes, please provide information below:

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  • If yes, please provide information below:

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  • Educational History (Optional)

  • * Please provide us with copies of any reports from evaluations that you may have, as well as a copy of the current 504 plan or IEP.

  • If yes, please provide the following information:

  • *If yes, you will need to complete a new intake packet for that child.

  • Psychological History (Optional)

  • Please indicate below whether or not there is a history of the following in your immediate family or in either biological parent’s extended family.

  • Birth and Developmental History (Optional)

  • Current Behavior Concerns (Optional)

  • Discipline Information (Optional)

  • Please rate what percentage of discipline is handled by each of the following:

  • Should be Empty: