VA NOVA Intake Assessment Form

Intake Form

Fill in every section of the form provided below to complete the intake process.
Client Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
Client Gender*
Service Area
Preferred Service Location*
How Did You Hear About Us?*
Service Needs and Client Information
Detail the reason ABA therapy services have been requested, at this time.*
What are the client's primary strengths?
What are the client's primary areas in need of improvement?
What are the client's preferred items/activities?
What items/activities does the client find unenjoyable?

Schedule of Availability for Services*

Rows	Time(s) Available
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Diagnosis Information

Fill in every section of the form provided below to complete the intake process.
Primary Diagnosis*
Severity Level *
Diagnosis Date*

MonthDayYear
Date
Diagnosing Provider Name/Practice Name
Diagnosing Provider Phone Number
Please enter a valid phone number.
Diagnosis Report (Preferred but Optional)

Cancelof
Additional Diagnosis Information
Secondary Diagnosis
Diagnosis Date

MonthDayYear
Date
Diagnosis Report (Optional)

Cancelof
Other Diagnosis
Diagnosis Date

MonthDayYear
Date
Diagnosis Report (Optional)

Cancelof

Health Insurance Information

Fill in every section of the form provided below to complete the intake process.
Primary Health Insurance Provider*
Member ID*
Health Insurance Phone Number (Used to Verify Insurance - See Back of Card)
Please enter a valid phone number.
Does your child have Medicaid Insurance?*
Medicaid ID
Does your child have the Virginia DD Waiver?
Is your child Echo Approved? (Tricare Only)*
Co-Pay Amount
Current Deductible
Front of Primary Insurance Card (Optional)

Cancelof
Back of Primary Insurance Card (Optional)

Cancelof
Secondary Health Insurance
Member ID
Health Insurance Phone Number (Use to Verify Insurance - See Back of Card)
Please enter a valid phone number.
Co-Pay
Deductible

Family Information/History

Fill in every section of the form provided below to complete the intake process.
Parent/Guardian #1
Parent/Guardian #1 Name*

First NameLast Name
Parent/Guardian #1 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #1 Email Address*
example@example.com
Parent/Guardian #1 Phone Number*
Please enter a valid phone number.
Parent/Guardian #1 Age
Parent/Guardian #1 Occupation
Parent/Guardian #1 Years in Occupational Role
Parent/Guardian #1 Able to Support Client w/ Occupational Income?
Parent/Guardian #1 Custody Status
Parent/Guardian #2
Parent/Guardian #2 Name

First NameLast Name
Parent/Guardian #1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #2 Email Addresss
example@example.com
Parent/Guardian #2 Phone Number
Please enter a valid phone number.
Parent/Guardian #2 Age
Parent/Guardian #2 Occupation
Parent/Guardian #2 Years in Occupational Role
Parent/Guardian #2 Able to Support Client w/ Occupational Income?
Parent/Guardian #2 Custody Status
Additional Family History Information
Other individuals routinely involved in the client’s care
Has the client been exposed to substance abuse, emotional abuse, sexual abuse, physical abuse, neglect or another trauma event?
Has child protective services (CPS) ever been involved with the family in the past?
Has there been any child custody decisions/involvement or orders of protection regarding the client?
Detail the religious or cultural practices of the family.
What community resources is the family currently utilizing?
Family Medical History (detail any chronic illness, contagious disease, history of substance/nicotine/alcohol abuse, mental health issue, genetic disorder, etc. among biological parents, biological siblings, biological grandparents, biological extended family or those individuals the client has frequent contact with)

Current/Previous Service Providers

Fill in every section of the form provided below to complete the intake process.
Primary Care Physician

Provider Information Details

Rows	Type Information Below
Provider Name
Practice Name
Practice Address
Practice Phone Number
Practice Fax Number
Service Hours Per Week
Last Visit Date

Developmental Pediatician

Provider Information Details

Rows	Type Information Below
Provider Name
Practice Name
Practice Address
Practice Phone Number
Practice Fax Number
Service Hours Per Week
Last Visit Date

Psychologist

Provider Information Details

Rows	Type Information Below
Provider Name
Practice Name
Practice Address
Practice Phone Number
Practice Fax Number
Service Hours Per Week
Last Visit Date

Neurologist

Provider Information Details

Rows	Type Information Below
Provider Name
Practice Name
Practice Address
Practice Phone Number
Practice Fax Number
Service Hours Per Week
Last Visit Date

SLP Service Provider

Provider Information Details

Rows	Type Information Below
Provider Name
Practice Name
Practice Address
Practice Phone Number
Practice Fax Number
Service Hours Per Week
Last Visit Date

OT Service Provider

Provider Information Details

Rows	Type Information Below
Provider Name
Practice Name
Practice Address
Practice Phone Number
Practice Fax Number
Service Hours Per Week
Last Visit Date

PT Service Provider

Provider Information Details

Rows	Type Information Below
Provider Name
Practice Name
Practice Address
Practice Phone Number
Practice Fax Number
Service Hours Per Week
Last Visit Date

Other Service Provider

Provider Information Details

Rows	Type Information Below
Provider Name
Practice Name
Practice Address
Practice Phone Number
Practice Fax Number
Service Hours Per Week
Last Visit Date

Select an Intake Meeting Date
Thank you for completing our intake form. We look forward to providing ABA services for you and your child. We provide in-home and center-based services which focus on increasing adaptive skills and reducing displays of maladaptive behavior. We provide direct therapy services, as well as, structured parent training. If you have any comments, questions or concerns, please email us at info@autismlearners.com.
Northern Virginia Calendar
Northern Virginia Intake Calendar
Tidewater-Virginia Beach Calendar
Tidewater-Virginia Beach Intake Calendar
Should be Empty:

Rows	Delayed	Normal	Advanced
Holding head up
Rolling over
Making eye contact
Smiling
Cooing or make sounds
Sitting up alone
Sleeping throughout the night
Holding bottle
Crawling
Imitating actions observed
Standing alone
Following simple directions
Playing simple games
Walking
Climbing onto items
Walking up and down stairs
Eating solid food
Feeding themselves finger food
Eating meal with utensil
Saying 1-3 intelligible words
Saying 5+ intelligible words
Speaking in 3+ word phrases
Staying dry throughout the day
Using bathroom independently
Staying dry throughout the night
Dressing themselves

Rows	Yes	No	Additional Information
Allergies
Contagious Disease(s)
Chronic Illness(es)
Trouble sleeping
Difficulty Eating
Difficulty Standing
Difficulty Ambulating
Chronic bedwetting
Deaf or blind
Engages in self-injurious behavior
PICA
Suicidal Ideation
Homicidal Ideation
History of substance abuse
History of nicotine/alcohol abuse
Other

Rows	Name	Dosage	Frequency	When	Start Date
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5

Rows	Yes	No	Additional Information
Psychological Services
One on One Student Aide
Speech Language Pathology
Occupational Therapy
Physical Therapy
Other Service(s)

Rows	Name	Location	Frequency	Setting Event	Additional Note
Behavior #1
Behavior #2
Behavior #3
Behavior #4

Intake Form

Service Needs and Client Information

Diagnosis Information

Additional Diagnosis Information

Health Insurance Information

Family Information/History

Parent/Guardian #1

Parent/Guardian #2

Additional Family History Information

Developmental History

Medical Information

School Information

Skills/Deficits Inquiry

Primary Communication Modality

Primary Communication Utterance Length

Social Behavior

Independence w/ Daily Living Skills

Current/Previous Service Providers

Primary Care Physician

Developmental Pediatician

Psychologist

Neurologist

SLP Service Provider

OT Service Provider

PT Service Provider

Other Service Provider

Select an Intake Meeting Date

Northern Virginia Calendar

Tidewater-Virginia Beach Calendar