Intake Form
Name of Client
*
First Name
Last Name
Medicaid Number
*
D.O.B
*
-
Month
-
Day
Year
Date
Age
*
Mother's Name
*
First Name
Last Name
Father's Name
*
First Name
Last Name
Emergency Contacts
*
Best Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you ever had ABA Therapy
*
Yes
No
Name of prior ABA Provider (If applicable)
Please list all known allergies(If none type N/A) *
Are we also able to contact you via text?
*
Yes
No
Alternative Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you or have you received any of the following Services?
Behavioral Therapy
Speech Therapy
Occupational Therapy
Physical Therapy
Morning from:
Time
AM
PM
*
to
Time
AM
PM
*
Afternoon from:
Time
AM
PM
*
to
Time
AM
PM
*
Please list the days you are available
*
Location of Services
*
In-Center
School
In-Home
School Name (If applicable)
*
Any important information about he client we should know?
*
Client's Favorite Toy
*
Client's Favorite Food
*
Favorite Activity (Gaming , Sports, Chess etc.)
*
What are some behaviors that concern you (Client Maladaptive Behaviors)
*
Primary Language
*
Do you have a preferred gender Registered Behavioral Technician?
*
Male
Female
No preference
How did you hear about us?
*
Submit
Should be Empty: