POSS ABA INTAKE FORM

In-Take 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 HIPPA 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
Today's Date
How did you hear of our practice? *

Search Engine Social Media Word of Mouth Other
General Information
Name (of person completing this form) *

First Name Last Name
Relationship to Child/Adolescent: *
Legal Name of Child/Adolescent *

First Name Last Name
Child/Adolescent's Date of Birth: *

Month Day Year
Date
Child/Adolescent Age: *
Ex: 5 years old
Parent/Guardian Name *

First Name Last Name
Parent/Guardian 2 Name

First Name Last Name
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Email *
example@example.com
Home Phone Number *
Please enter a valid phone number.
Parent/Guardian (Employer Name): *
Parent/Guardian (Employer Address) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian (Employer Phone #): *
Please enter a valid phone number.
Insurance Information
Name of Policy Holder: *
Policy Holder Date of Birth: *

Month Day Year
Date
Policy Holder Social Security # *
If the child is the policy holder, please note SS#. All information is confidential.
Name of Insurance: *
Horizon, Aetna, United Health Care
Insurance Phone Number *
Please enter a valid phone number.
Member ID Number: *
Group ID Number: *
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
Physician Name:
Physician Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Physician Phone Number
Please enter a valid phone number.
Child/Adolescent's Current Hight:
ft. ___ in. ____
Child/Adolescent's Current Weight:
lbs
Which hand does your child/adolescent show dominance?

Left Right No preference
Does your child/adolescent have any current health conditions, including infectious diseases?

Yes No
If yes, please explain below:
Please also provide the following:
List any operations, serious illnesses, injuries (especially head), hospitalizations, allergies, ear infections, or other special conditions your child/adolescent has had.
Does your child/adolescent have any vision problems?

Yes No
If yes, please explain below and if there are any treatments currently being used for correction.
Does your child/adolescent have any hearing problems?

Yes No
If yes, please explain below and if there are any treatments currently being used for correction.
Does your child/adolescent have a history of seizures?

Yes No
If yes, please explain below the types of seizures and current treatment:
Is your child/adolescent currently taking any medications?

Yes No
If yes, please provide the following information:
Does your child/adolescent have any allergies to medications?

Yes No
If yes, please describe, including any adverse reactions:
Does your child/adolescent have any other allergies (seasonal, food, etc.)?

Yes No
If yes, please describe, including any adverse reactions and if any epi pen is needed:
Does your child/adolescent currently have a diagnosis?

Yes No
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 Information
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.
Does your child/adolescent currently receive behavioral services with another provider?

Yes No
If yes, please provide information below:
Name of Behavioral Provider

First Name Last Name
Provider Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Provider Phone Number
Please enter a valid phone number.
Email
example@example.com
Does your child/adolescent currently receive speech therapy services?

Yes No
If yes, please provide information below:
Name of Speech Therapy Provider

First Name Last Name
Provider Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Provider Phone Number
Please enter a valid phone number.
Email
example@example.com
Does your child/adolescent currently receive occupational therapy services?

Yes No
If yes, please provide information below:
Name of Occupational Therapy Provider:

First Name Last Name
Provider Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Provider Phone Number
Please enter a valid phone number.
Email
example@example.com
Does your child/adolescent currently receive physical therapy services?

Yes No
If yes, please provide information below:
Name of Physical Therapy Provider

First Name Last Name
Provider Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Provider Phone Number
Please enter a valid phone number.
Email
example@example.com
Does your child/adolescent currently receive psychiatric therapy services?

Yes No
If yes, please provide information below:
Name of Psychiatric Provider:

First Name Last Name
Provider Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Provider Phone Number
Please enter a valid phone number.
Email
example@example.com
Does your child/adolescent currently receive any other services?

Yes No
If yes, please provide information below:
Name of Other Provider

First Name Last Name
Provider Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Provider Phone Number
Please enter a valid phone number.
Email
example@example.com
Educational History
Is your child/adolescent currently classified for special education services?

Yes No
* 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.
Does either parent/guardian’s job require him/her to be away from home for long hours or extended periods of time that might prevent them from being involved in ABA services and parent training?

Yes No
Marital Status

Married Civil Union Remarried Divorced Separated Widowed Single Cohabitant
If divorced, who has legal custody?
Is it full or joint custody?
If yes, please provide the following information:
Please indicate and describe whether any of the siblings have any special needs, diagnosis, or concerns:
Are you interested in seeking services for any of the siblings with special needs?

Yes No Not applicable
*If yes, you will need to complete a new intake packet for that child.
Are there any other individuals residing in the house or elsewhere that play a significant role on how this child is raised?

Yes No
* If yes, please identify who else is involved in raising the child and their relationship to the child.
Psychological History
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.
If yes, please indicate who in the family currently has or has had these diagnoses:
Type aHas your child/adolescent had an outside psychological or psychiatric evaluation?

Yes No
Has your child/adolescent ever been hospitalized for a psychiatric condition?

Yes No
Please provide us with any other information on the psychological history that you feel would be helpful to us in understanding your child/adolescent.
Birth and Developmental History
Did the birth mother receive regular prenatal care?

Yes No
Were there any complications with the pregnancy?

Yes No
If yes, please describe the complications below and treatment details.
Was the birth full term?

Yes No
If no, please provide details.
What was the type of delivery?

Spontaneous Induced Vaginal C-Section
Were there any complications during delivery?

Yes No
If yes, please describe the complications below and treatment details.
What was your child/adolescent's birth weight?
lbs. oz.
Were there any concerns at birth?

Yes No
If yes, please describe the concerns and treatment details.
Were there any developmental milestones that your child was delayed in or did not achieve?

Yes No
If yes, please identify those milestones below.
Current Behavior Concerns
If applicable, please describe sleep problems below:
If applicable, please list drug use/abuse below:
Are there any current or past relevant legal issues pending with your child/adolescent?

No Yes
If yes, please describe below:
Please state the goals that you have for your child/adolescent while engaging in a behavioral program.
Discipline Information
Please rate what percentage of discipline is handled by each of the following:
Parent/Guardian 1:
XX%
Relationship to Child/Adolescent:
Parent/Guardian 2:
XX%
Relationship to Child/Adolescent:
What is typically used for disciplining your child/adolescent (e.g., timeout, assigning chores, physical/corporal punishment, etc.)?
Are there any spiritual beliefs or values that you think may impact how you provide discipline or behavioral supports to your child?

Yes No
If yes, please describe below.
Are there any cultural beliefs or values that you think may impact how you provide discipline or behavioral supports to your child?

Yes No
If yes, please describe below.
Front of Insurance Card *

Cancel of
Back of Insurance Card *

Cancel of
Report with ASD Diagnosis/ Doctor's Script with ASD Diagnosis *

Cancel of
Additional Uploads

Ex: IEP or 504 Plan
Cancel of
Should be Empty:

In-Take Questionnaire ABA Therapy

General Information

Insurance Information

Medical Information

Current/Previous Therapy Provider Information

Educational History

Psychological History

Birth and Developmental History

Current Behavior Concerns

Discipline Information