New Patient Intake Form
Welcome to our Intake Process
Patient Demographic Information
Child's Name
*
First Name
Last Name
Child's Date or Birth
*
-
Month
-
Day
Year
Date
Child's Gender
Please Select
Male
Female
Child's Social Security Number
Address where child resides:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Primary email address:
*
example@example.com
Additional email address:
example@example.com
Please indicate best method of contact:
*
Email
Text
Phone call
Who has custody of the child?
*
Parents
Guardian
Guardian's Name:
*
First Name
Last Name
Guardian's phone number:
*
Please enter a valid phone number.
Mother's Name:
*
First Name
Last Name
Mother's mobile phone number:
*
Please enter a valid phone number.
Father's Name:
*
First Name
Last Name
Father's mobile number:
*
Please enter a valid phone number.
Who is filling out this form:
*
Please Select
Mother
Father
Guardian
Name of person filling out this form:
*
First Name
Last Name
Does the child have siblings?
*
Yes
No
Names of sibling(s):
*
Other than siblings does anyone else live in the home?
*
Yes
No
List all people who live in the home and relationship:
*
Any food or drug allergies/food restrictions?
*
Yes
No
List known allergies/food restrictions:
*
Primary language spoken by child:
*
Emergency contact name
*
First Name
Last Name
List the name of adults allowed to pick up child from clinic services:
*
Adult Name
Relation to child
Phone number
Adult 1 name
Adult 2 name
Adult 3 name
Adult 4 name
Emergency contact phone number:
*
Please enter a valid phone number.
Emergency contact relation to child:
*
Please list the reason for the referral for ABA services (e.g. behaviors of concern):
*
How did you hear about us?
*
Pediatrician
Specialist
Social Worker
Facebook
Instagram
Google Search
School/Daycare
Smart Endeavors ABA Website
Insurance Company
Another ABA Agency
Autism Navigator
Friend
Other
Insurance Information
Is your current insurance Medicaid or Medicaid type plan (Sunshine, Humana, Molina)
*
Yes
No
Current insurance carrier:
*
Insurance subscriber's full name:
*
Insurance subscriber's DOB:
*
-
Month
-
Day
Year
Date
Insurance subscribers social security number
*
Is insurance subscriber's address the same as your child's?
*
Yes
No
Insurance subscriber's address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please attach insurance card front and back.
*
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Caregiver/Guardian Drivers License
*
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Secondary Insurance
NOTE: If you do not report a secondary insurance when you in fact have one, claims may be denied and you will be responsible for the bill.
Do you have more than one insurance plan other than the one mentioned above?
Yes
No
Secondary insurance carrier:
*
Company Name
Secondary insurance subscriber's full name:
*
Insurance subscriber's DOB:
*
-
Month
-
Day
Year
Date
Secondary insurance subscriber's social security number
*
Is insurance subscriber's address the same as your child's?
*
Yes
No
Insurance subscriber's address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please attach insurance card front and back.
*
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Secondary insurance subscribers driver license
*
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Child's History
Referring provider's name:
*
First Name
Last Name
Copy of referral and diagnostic assessment.
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Primary physician's name:
*
First Name
Last Name
Does your child take any medication
*
Yes
No
Medications currently taking:
*
Dosage
What is it for
Times per day
Any adverse symptoms
Medication
Medication
Medication
Medication
Type of delivery?
*
Please Select
Vaginally
C-section
How many weeks was baby delivered?
*
Please Select
<37 weeks (pre-term)
>37 weeks (full-term)
Age began walking:
*
Age began talking
*
Enter N/A if child does not say words
Diagnostic Information
Diagnosis and severity level
*
No Autism
Mild Autism (Severity Level I in the DSM-V)
Moderate Autism (Severity Level II in the DSM-V)
Severe Autism (Severity Level III in the DSM-V)
Seeking Autism Screening (ADOS)
Other psychological diagnosis (select all that apply):
ADHD (attention deficit hyperactivity disorder) (F90. 0)
ODD (oppositional defiant disorder) (F91.3)
Developmental Disability (R62.50)
Intellectual Disability (F70)
Anxiety (F41. 8)
Sadness or Depression (F32. 9)
Bipolar Disorder (F31. 9)
Hallucinations (R44. 3)
Delusions
Suicidal Ideation/Attempts ( R45.81)
Bulimia (F50. 2)
Anorexia (R63. 0)
Insomnia (G47.00)
Other
Emergency/Crisis Situations
Have emergency procedures (involvement of medical personnel or law enforcement due to problem behavior) been implemented in the last 6 months?
*
Please Select
Never
Once
Twice
More than twice
Select all that apply to any of the emergency procedures:
*
Please Select
restricting movement or access to preferred items or normal environment with physical redirection, blocking, devices, barriers, furniture, locks
seclusion (isolating the individual from others)
manual restraint (physically holding the person to restrict movement)
mechanical restraint (applying a device to the person’s body or limb to restrict movement)
behavior protective equipment (e.g., helmet for headbanging, gloves for hand-mouthing, padded clothing, belt, strap, harness, splint, other
Current Behaviors
Select all behaviors that your child has engaged in:
*
Elopement (leaving the area of supervision)
Suicide attempts
Suicidal talk or illustration - threats to cause harm to self (with ability to follow-through)
Cutting self (covert, non-suicidal)
Illegal drug use
Prostitution
Sexting (sending texts with nude or suggestive pictures)
Climbing - presenting risk of fall
Property misuse presenting a danger to self (e.g., electrical shock, cuts)
Bruxism (teeth grinding)
Trichotillomania (hair removal)
Mouthing unsafe objects
Pica (consuming inedibles, toxic substances)
Rectal digging, feces smearing
Feces eating
Trichophagia (hair eating)
Polyphagia (excessive eating)
Polydipsia (excessive drinking)
Excessive vomiting (rumination)
Bulimia (vomitting food)
Anorexia
Food refusal (over-selectivity that impacts nutrition and results in weight loss)
Failure to thrive
Aerophagia (air swallowing)
Biting self
Nail biting, picking, removal
Skin picking, pinching, scratching
Head slapping/hitting (e.g., hand/knee/object to self)
Head banging on hard surfaces
Head banging on soft surfaces
Eye poking (self)
Refusal to comply with medical or dental care/evaluations
Refusal to comply with hygiene care/routines that impacts health and/or social acceptance
None
Other
Provide the frequency of elopement (leaving area of supervision):
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of suicide attempts:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of suicidal talk or illustration/threats:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of cutting self, non-suicidal:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of illegal drug use:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of prostitution:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of sexting:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of climbing- presenting risk of fall:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of property misuse presenting a danger to self (e.g., electrical shock, cuts):
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of bruxism (teeth grinding:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Trichotillomania (hair removal):
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Mouthing unsafe objects:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Pica (consuming inedibles, toxic substances):
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Rectal digging, feces smearing:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Feces eating:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Trichophagia (hair eating):
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Polyphagia (excessive eating):
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Polydipsia (excessive drinking):
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Excessive vomiting (rumination):
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Bulimia:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Anorexia:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Food refusal (over-selectivity that impacts nutrition and results in weight loss):
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Failure to thrive:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Aerophagia (air swallowing):
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Biting self:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Nail biting, picking, removal:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Skin picking, pinching, scratching:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Head slapping/hitting (e.g., hand/knee/object to self):
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Head banging on hard surfaces:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Head banging on soft surfaces:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Eye poking (self):
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Refusal to comply with medical or dental care/evaluations:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Refusal to comply with hygiene care/routines that impacts health and/or social acceptance:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Provide the frequency of Other:
*
More than 5 time per day
More than 1 time per day but less than 5
More than 1 time per week but less than 1 time per day
1 time per week or less often
Has your child shown aggression to others - actual contacts and attempts ("near misses") - intensity (force), frequency and/or duration that caused or presented imminent risk of severe injury in the last 6 months?
*
Yes
No
Check all types of aggression to others that apply:
*
Head butt, hit, slap, pinch, scratch, hair pull, or bite adults
Head hit, slap, pinch, scratch, hair pull, or bite children or other vulnerable persons (aged, disabled)
Striking with or throwing objects
Spitting, licking, wiping saliva
Contacting genitalia, breast, butt - forced kissing, licking
Property destruction or disruption (caused or presented imminent risk of high value property loss or repair in the last 6 months)?
*
Yes
No
Check all that apply to property destruction:
*
Property destruction
Throwing objects
Pushing objects off tables (e.g., during instruction)
Feces smearing
Spitting, licking
Check all severe atypical behaviors that apply to your child:
*
Fire setting or play with matches, lighters or other inflammables
Verbal or illustrated threats to cause harm to others
Coercion of other children or other vulnerable persons (aged, disabled)
Selective mutism (chooses not to talk)
Ritualistic, intense preoccupation with topics (verbal)
Gazing stereotypy (staring into space)
Hyper-reactivity to sensory input
Hypo-reactivity to sensory input
Hyperactivity
Impulsivity
Inattention
Severe insomnia, excessive sleeping during day (sleep disorder)
Property theft, extortion
Lying
Vandalism (destruction of property)
Verbal threats of sexual nature
Saying inappropriate words (e.g., swear, racial slur, LGBTQ slur, name calling, sexual terms)
Undressing in public, exposing own genitalia, or masturbation in public
Voyeurism (watching people inappropriately)
Tantrums - not age typical for a 2-3 year old child
Verbal refusal (says no to caregiver demands)
Physical refusal to move (e.g., laying on ground, squatting)
Screaming, yelling, crying
Bolting (running away from instruction or activity, but remaining in safe area)
Saliva play or smearing
Enuresis (urinating on self)
Encopresis (pooping self)
Feces play or smearing
Perseverative behaviors
Ritualistic, intense preoccupation with, obsessive repetition of actions (e.g., hand washing, checking lights off, door locked)
Repeating task to obtain perfection
Movement (motor) tics
Movement stereotypy (e.g., hand flapping, spinning objects, spinning self, rocking)
Non-typical toy play
Lining up objects
Counting
Hoarding objects
Difficulty with expressive language (communicating what the child wants/needs or does not want/need)
Difficulty with receptive language (comprehension)
Difficulty with initiating, sustaining, and/or responding to communicative and social interactions with others
Poor understanding or use of non-verbal communication
Vocal tics
Vocal or auditory stereotypy (e.g., delayed echolalia/repeating, singing, noises)
Echolalia (repeating others words after them)
Truancy (skipping school)
None
Was medical evaluation or care required as a result of a behavior?
*
Yes
No
If yes, please describe:
*
Was another recipient or vulnerable person involved, assaulted or injured as a result of a behavior?
*
Yes
No
If yes, please describe:
*
Was a law enforcement officer involved as a result of the behavior?
*
Yes
No
Skill Deficits
Deficits in adaptive daily living skills (e.g., self help, self preservation)?
*
enuresis (self-urinating)
encopresis (self-defecating)
difficulty with toileting
lack of safety awareness (e.g., regarding hot or sharp surfaces, crossing the street, strangers, etc.)
impulsivity
refusal to comply with hygiene care/routines (e.g., dressing, bathing, brushing teeth, etc.) that impacts health or social acceptance
food refusal (over-selectivity that impacts nutrition and results in weight loss)
sleep problems
bedwetting
none
Deficits in communication skills?
*
Yes
No
For communication deficits select all that apply:
*
difficulty with expressive language (communicating what the recipient wants/needs or does not want/need)
difficulty with receptive language (understanding and following instructions)
poor understanding or use of non-verbal communication
selective mutism (chooses not to talk)
Non-verbal
How does your child communicate?
*
Please Select
vocal communication
American sign language
picture exchange communication system (PECS)
augmentative and alternative communication device (AAC)
non-verbal
Deficits in social skills?
*
Yes
No
For social skills deficits select all that apply:
*
difficulty with initiating, sustaining, and/or responding to communicative and social interactions with others
poor eye contact
inattention
hyperactivity
difficulty with transitions from preferred to nonpreferred activities
isolated socially from peers
difficulty making friends
problems keeping friends
Therapy Information
Has your child previously been in ABA therapy?
*
Yes
No
How many hours per week of ABA was your child previously completing?
*
Name of previous ABA therapy provider:
*
Please upload previous behavior plan
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Desired therapy setting:
*
School (public school)
School (private school)
Daycare
Home
Clinic
Community
Name of School Currently Attending
*
Desired therapy schedule days:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Desired therapy time:
*
Morning (8:00 AM – 12:00 PM)
Afternoon (12:00 PM – 3:00 PM)
Evening (3:00 PM – 6:00 PM)
Select the following other therapies your child is currently attending
*
Occupational
Physical
Speech
Talking
None
Other
Educational Information
Is your child currently attending school?
*
Yes
No
Name of school currently attending:
*
What is the current grade?
*
Is your child attending school virtually?
*
Yes
No
Classroom type:
*
General Education
Special education
Attach IEP:
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Submit
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