• Spectrum ABA Intake Packet

    Spectrum ABA Intake Packet

  • Hello, and welcome to Spectrum ABA's electronic intake packet.  Please take the time to answer as many questions as you can as the information in this packet will help our team best serve the client.  If you have questions or need assistance, please email admin@spectrum-aba.com.

    Note: In the form you will be able to upload copies of your insurance card(s) and your diagnosis paperwork.  If you do not have these at this time, you can upload separately, but it is preferred to attach with the packet if possible.

  • Today's Date*
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  • Person Completing this Form:

  • Are you authorized to consent for this individual's healthcare?*

  • Basic Client Information:

  • Client's Date of Birth*
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  • Client's Gender

  • Parent / Guardian Information - First:

  • Date of Birth*
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  •  -

  • Parent / Guardian Information - Second:

  • Date of Birth*
     - -
  •  -

  • Insurance Information

  • Do you have Secondary Insurance? If Yes, fill out below.*
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  • Family Information

  • Family's Primary Language?*

  • Who is Responsible for Client Medical Decisions?*

  • Divorced/Separated?
  • If Yes, What is the Custody Arrangement?

  • Emergency Contact Information

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  • Client Medical Information

  • Rows
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  • Other Current and Past Services

    (Speech, OT, PT, ABA, etc.)
  • Currently Receiving Services?
  • Currently Receiving Services?
  • Currently Receiving Services?
  • Currently Receiving Services?
  • Currently Receiving Services?
  • Has the Client Received ABA in the Past?
  • If Yes, What was the Start Date?
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  • If Yes, What was the End Date?
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  • ABA Service Information

  • ABA Service Location(s) Requested - Select ALL that Apply*

  • Important: Please list all available service times below.  The more availability the client has could help reduce wait list time.  Please be as accurate as possible and check ALL of the hours for each day of the week that you have available.  If the client availability splits an hour, go ahead and check the box.  For example, if availability starts at 9:00am, check the 8:30-9:30am box.

    Note:  Sessions must be a minimum of 3 hours in length, with a minimum of 15 hours per week of ABA therapy.

  • Rows
  • Rows

  • Client's Educational Background

  • Is the Client Currently Enrolled in School?*

  • If Yes, complete the rest of this section.  If not, please skip to next page.

  • Is the Client Receiving Special Services in the School?

  • Evaluations and Assessments

  • Below you can attach copies of different assessments and evaluations.  If you do not have the files accessible at this time, you can e-mail copies to admin@spectrum-aba.com.

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  • Signatures and Submission

  • I hereby certify that the above statements and information are true and correct to the best of my knowledge and understand all information in this packet will become part of the client's file.

  • Date*
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  • Date
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  • Should be Empty: