Client Intake Form

New Patient Intake Form

Welcome to our Intake Process
Patient Demographic Information
Child's Name

First NameLast Name
Child's Date or Birth

MonthDayYear
Date
Child's Gender
Child's Social Security Number
Address where child resides:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary email address:
example@example.com
Additional email address:
example@example.com
Please indicate best method of contact:
Who has custody of the child?
Guardian's Name:

First NameLast Name
Guardian's phone number:
Please enter a valid phone number.Format: (000) 000-0000.
Mother's Name:

First NameLast Name
Mother's mobile phone number:
Please enter a valid phone number.Format: (000) 000-0000.
Father's Name:

First NameLast Name
Father's mobile number:
Please enter a valid phone number.Format: (000) 000-0000.
Who is filling out this form:
Name of person filling out this form:

First NameLast Name
Does the child have siblings?
Names of sibling(s):
Other than siblings does anyone else live in the home?
List all people who live in the home and relationship:
Any food or drug allergies/food restrictions?
List known allergies/food restrictions:
Primary language spoken by child:
Emergency contact name

First NameLast Name

List the name of adults allowed to pick up child from clinic services:

Rows	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.Format: (000) 000-0000.
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?

Other
Insurance Information
Is your current insurance Medicaid or Medicaid type plan (Sunshine, Humana, Molina)
Current insurance carrier:
Insurance subscriber's full name:
Insurance subscriber's DOB:

MonthDayYear
Date
Insurance subscribers social security number
Is insurance subscriber's address the same as your child's?
Insurance subscriber's address:

Street Address

Street Address Line 2

CityState / 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?
Secondary insurance carrier:
Company Name
Secondary insurance subscriber's full name:
Insurance subscriber's DOB:

MonthDayYear
Date
Secondary insurance subscriber's social security number
Is insurance subscriber's address the same as your child's?
Insurance subscriber's address:

Street Address

Street Address Line 2

CityState / 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 NameLast Name
Copy of referral and diagnostic assessment.

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Primary physician's name:

First NameLast Name
Does your child take any medication

Type of delivery?
How many weeks was baby delivered?
Age began walking:
Age began talking
Enter N/A if child does not say words
Diagnostic Information
Diagnosis and severity level
Other psychological diagnosis (select all that apply):

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?
Select all that apply to any of the emergency procedures:
Current Behaviors
Select all behaviors that your child has engaged in:

Other
Provide the frequency of elopement (leaving area of supervision):
Provide the frequency of suicide attempts:
Provide the frequency of suicidal talk or illustration/threats:
Provide the frequency of cutting self, non-suicidal:
Provide the frequency of illegal drug use:
Provide the frequency of prostitution:
Provide the frequency of sexting:
Provide the frequency of climbing- presenting risk of fall:
Provide the frequency of property misuse presenting a danger to self (e.g., electrical shock, cuts):
Provide the frequency of bruxism (teeth grinding:
Provide the frequency of Trichotillomania (hair removal):
Provide the frequency of Mouthing unsafe objects:
Provide the frequency of Pica (consuming inedibles, toxic substances):
Provide the frequency of Rectal digging, feces smearing:
Provide the frequency of Feces eating:
Provide the frequency of Trichophagia (hair eating):
Provide the frequency of Polyphagia (excessive eating):
Provide the frequency of Polydipsia (excessive drinking):
Provide the frequency of Excessive vomiting (rumination):
Provide the frequency of Bulimia:
Provide the frequency of Anorexia:
Provide the frequency of Food refusal (over-selectivity that impacts nutrition and results in weight loss):
Provide the frequency of Failure to thrive:
Provide the frequency of Aerophagia (air swallowing):
Provide the frequency of Biting self:
Provide the frequency of Nail biting, picking, removal:
Provide the frequency of Skin picking, pinching, scratching:
Provide the frequency of Head slapping/hitting (e.g., hand/knee/object to self):
Provide the frequency of Head banging on hard surfaces:
Provide the frequency of Head banging on soft surfaces:
Provide the frequency of Eye poking (self):
Provide the frequency of Refusal to comply with medical or dental care/evaluations:
Provide the frequency of Refusal to comply with hygiene care/routines that impacts health and/or social acceptance:
Provide the frequency of Other:
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?
Check all types of aggression to others that apply:
Property destruction or disruption (caused or presented imminent risk of high value property loss or repair in the last 6 months)?
Check all that apply to property destruction:
Check all severe atypical behaviors that apply to your child:
Was medical evaluation or care required as a result of a behavior?
If yes, please describe:
Was another recipient or vulnerable person involved, assaulted or injured as a result of a behavior?
If yes, please describe:
Was a law enforcement officer involved as a result of the behavior?
Skill Deficits
Deficits in adaptive daily living skills (e.g., self help, self preservation)?
Deficits in communication skills?
For communication deficits select all that apply:
How does your child communicate?
Deficits in social skills?
For social skills deficits select all that apply:
Therapy Information
Has your child previously been in ABA therapy?
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:
Name of School Currently Attending
Desired therapy schedule days:
Desired therapy time:
Select the following other therapies your child is currently attending

Other
Educational Information
Is your child currently attending school?
Name of school currently attending:
What is the current grade?
Is your child attending school virtually?
Classroom type:
Attach IEP:

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Should be Empty:

Rows	Dosage	What is it for	Times per day	Any adverse symptoms
Medication
Medication
Medication
Medication

New Patient Intake Form

Patient Demographic Information

Insurance Information

Secondary Insurance

Child's History

Diagnostic Information

Emergency/Crisis Situations

Current Behaviors

Skill Deficits

Therapy Information

Educational Information