Child Intake Form

Client Intake Form
CLIENT'S INFORMATION
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?*
If you chose "Other" can you provide any additional information?
PARENT/GUARDIAN INFORMATION
Name*

First NameLast Name
Relation to Client*
If you selected "Other" please clarify your relation to the client:*
YesNo
If you are the client's legal guardian, please upload that documentation here.

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Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
In-Home TherapyWestoverLeon Springs
Submit Photo of the front of the guardian's identification (ID)*

PRIMARY INSURANCE INFORMATION

Please provide details below on any insurance policies that cover the client.
Commercial policyMedicaid policy
What is your primary Medicaid insurance plan?*
What is your primary Commercial insurance plan?*
What is the subscriber's full name? (for Commercial policies, this is the main policy holder)*

First NameLast Name
For Tricare TriWest Subscribers, what is the Sponsor's Social Security Number? TriWest will require this information for us to verify the client's eligibility and plan information.*
What is the Subscriber's Date of Birth (insurance requires this information when submitting authorization requests and claims)*

MonthDayYear
Date
Submit Photo of Front of PRIMARY Insurance Card*
Submit Photo of Back of PRIMARY Insurance Card*
YesNo

SECONDARY INSURANCE INFORMATION
Commercial policyMedicaid policy
What is your secondary Medicaid insurance plan?*
What is your secondary Commercial insurance plan?*
What is the subscriber's full name? (for Commercial policies, this is the main policy holder)*

First NameLast Name
For Tricare TriWest Subscribers, what is the Sponsor's Social Security Number? TriWest will require this information for us to verify the client's eligibility and plan information.*
What is the Subscriber's Date of Birth (insurance requires this information when submitting authorization requests and claims)*

MonthDayYear
Date
Submit Photo of Front of SECONDARY Insurance Card*
Submit Photo of Back of SECONDARY Insurance Card*

REQUIRED DOCUMENTS

The documents below are required by insurance for us to submit an authorization request for services.
Please submit a copy of the referral document here.

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Submit a copy of your child's autism diagnosis report (if available)

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Submit a copy of your child's DSM-5 Checklist (TRICARE INSURANCE ONLY)

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Please add a copy of the referral if you have a copy.

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PRIMARY CARE PROVIDER

Please provide information below on the client's primary care provider (PCP)
Who is your child's primary care physician?*

First NameLast Name
What is the name of the clinic or practice where your child sees their primary care physician?*
YesNo

CONSENT TO PROVIDE TREATMENT
As part of the process for beginning Applied Behavioral Analysis (ABA) services, we will conduct an Initial Assessment. This Initial Assessment will help determine if ABA services would be an appropriate treatment option, and if so, what intensity of services would be most appropriate for the client's specific needs. Once the Initial Assesment is completed, your family may choose to begin ongoing ABA services for the client.

Some things to be aware of regarding the Initial Assessment:

The Initial Assessment will be conducted in a timely manner. Please be aware that most insurance companies only allow us to bill a maximum of 2 hours per day to complete the assessment and write the Treatment Plan. This means you will see several dates of services on the Explanation of Benefits you receive from your Insurance Company as it can take up to 8 total hours to complete the Treatment Plan.
We will provide you with a full copy of the Treatment Plan that details recommended treatment and service level that is developed as part of the assesement process. You have the right to review and comment on the Initial Assessment and Treatment Plan.
No services will be started, changed, or ended without notice to you.

Your signature below indicates that you understand and consent to the following:
- I voluntarily consent to allow Little Spurs Autism Centers providers to perform necessary evaluations and regular treatment.
- I have the right to discuss any treatment with my Board Certified Behavioral Analyst (BCBA). I am encouraged to ask questions and share any concerns I may have.
- This consent is valid until it is revoked via written and signed revocation form submitted to the client's regular clinic site location.
- I understand that any information collected during the process of treatment will remain strictly confidential per the Health Insurance Portability and Accountability Act (HIPAA). Federal Law requires you to provide us with a written and signed authorization if you request for us to release any information to any agency or individual outside of Little Spurs Autism Centers.
Name*

First NameLast Name
Signature*

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HIPAA NOTICE & PRIVACY PRACTICES
Little Spurs Autism Centers does not use or disclose your Protected Health Information unless permitted or required by law. Your signature below acknowledges that you have received a copy of the Notice of Privacy Practices. All information received and/or obtained through Little Spurs Autism Centers is considered confidential. The client's information is kept in a secure, locked location and monitored to ensure the preservation of confidentiality. Our team will only release Protected Health Information upon receipt of an original copy of a signed and dated Release of Information completed by the parent or legal guardian of the client.

You can review our privacy practices in full using this link (clicking on the link will open the document in a new tab): https://littlespursautism.com/wp-content/uploads/2025/05/LSAC-Notice-of-Privacy-Practices_05202025.pdf
Name*

First NameLast Name
Signature

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FINANCIAL POLICY
Little Spurs Autism Centers will issue regular invoices for any patient responsibility portions of insurance charges, such as coinsurance, copayments, and deductibles. During the intake process, our team will provide you with an estimate of anticipated charges for your course of treatment. Please note that final amounts due cannot be determined until your insurance provider has processed the claim and issued an Explanation of Benefits (EOB). We require all clients to keep a Credit Card Authorization on file that will be charged on a weekly basis for services rendered the prior week. If you are unable to pay the full balance at that time, please contact our Billing Department at the contact information listed below to discuss your potential options. Patients paying out of pocket (“private pay”) are required to remit full payment prior to receiving services. This policy is strictly enforced. As a convenience, you may choose to store a payment card on file for automatic weekly or monthly billing. However, this option is entirely voluntary.

As the person bringing the client in for treatment, (the parent, the guardian and/or the custodian of the patient, or a person as allowed by Texas Law), I agree to be responsible for all services rendered. I hold The Practice harmless for attempts to collect regardless of parental, guardian, or custodial financial responsibility. I agree to be responsible for payment regardless of any divorce, separation or other outside agreements that may or may not be in effect at the time of service.

Insurance is a contract between you and your insurance company. In most cases, we are not a party to this contract. We will bill your primary insurance company on your behalf as a courtesy to you. To properly bill your insurance company, we require that you disclose all insurance information, including primary and secondary insurance, as well as any change of insurance information. It is your responsibility to notify our office promptly of any patient information changes (ie, address, name, insurance information, lapse in insurance policy, change to new policy) to facilitate appropriate billing for the services rendered to you. Failure to provide complete and accurate insurance information may result in the entire bill being categorized as a patient’s responsibility. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and benefits. If your insurance company is not contracted with us, you agree to pay any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance. If we are out of network for your insurance company and your insurance pays you directly, you are responsible for payment and agree to forward the payment to us immediately.

BILLING DEPARTMENT CONTACT INFORMATION
- PHONE: 210-281-8669, Option 2 (available Mon - Fri from 8am - 5pm)
- EMAIL: LSACBilling@littlespurs.com
Name*

First NameLast Name
Signature

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AUTHORIZATIONS
YesNo
YesNo
MARKETING
I hereby consent to allow Little Spurs Autism Centers to communicate with me via email regarding details of my child's visits. This may include, but is not limited to, information about my diagnosis, date of service, treatment plan, and other relevant healthcare information. I understand that while all reasonable measures will be taken to protect my privacy, email may not be a fully secure form of communication. I understand that this information may be used to inform me about business purposes such as, surveys, announcements, events, articles, relevant services, products, or promotions that may be of interest based on my healthcare history. If you wish not to receive any of the following information via email, please inform the Center Manager or opt out of the email program at any time by selecting "unsubscribe" at the bottom of the email. Please note that a patient may not opt out of healthcare related communications (such as notices of closure, updates about center policies, etc.).

TEXT MESSAGING
Text messages. By providing us with your wireless phone number, you consent to Little Spurs Autism Centers sending you informational text messages related to your child's therapy services. You can unsubscribe from text messages by replying STOP to any of these text messages. Messaging and data charges may apply to any text message you receive or send. Please contact your wireless carrier if you have questions about messaging or data charges.

EMAIL
Health care providers using the Service may contact you via email to remind you of an appointment and to provide general health/medication/insurance reminders and information and you hereby agree to receive such messages via email. By consenting to receive any electronic information from Little Spurs via text message or email, you understand these methods of communication may not be secure and there may be some level of risk that the information in the email or text message could be read by a third party or be otherwise subject to unauthorized access or use. You are advised not to share personal health information via insecure text message or insecure email. Little Spurs is not responsible for unauthorized access of protected health information while in transmission to the individual based on the individual's request. Furthermore, Little Spurs is not responsible for safeguarding information once delivered. By agreeing to these terms, you agree to receive insecure text messages at your given phone number or any number forwarded or transferred to that number and to receive insecure emails. The consent to receive text messages or email will apply to all future appointment reminders/feedback/health/medication information and other communications unless you request us, as applicable, to stop sending the messages by replying "STOP" to a text message, unsubscribing from email, or other method designated by the health care provider or our Service. Please be aware that if you choose to stop receiving certain marketing emails or text messages, you may still receive certain important non-marketing messages related to your appointments. If you are not the intended recipient of any text messages or emails sent by Little Spurs, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited and you should promptly delete this information. Also, if you are not the intended recipient to text messages please reply "STOP" to any such text messages you receive. See Little Spurs Privacy Policy for More Information
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Should be Empty:

Client Intake Form

CLIENT'S INFORMATION

PARENT/GUARDIAN INFORMATION

PRIMARY INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION

REQUIRED DOCUMENTS

PRIMARY CARE PROVIDER

CONSENT TO PROVIDE TREATMENT

HIPAA NOTICE & PRIVACY PRACTICES

FINANCIAL POLICY

AUTHORIZATIONS