ABA Therapy Initial Intake Form (Compass Center, Inc.) | ENGLISH Form Logo
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  • ABA Therapy Initial Intake Form

    Compass Center, Inc

  • Dear Parent/Caregiver,


    Thank you for considering Compass Center, Inc. as your trusted ABA therapy provider. We appreciate the opportunity to work with your child and your family.


    To ensure a seamless intake process, kindly fill out the initial intake form with as much detail as possible. 


    Additionally, please have the following documents ready prior to filling out the form:

    • Insurance Cards: Picture of both FRONT and BACK (REQUIRED)
    • Diagnostic Information: Diagnosis, date of diagnosis, name of diagnostician, Diagnostic report (REQUIRED)
    • IEP or 504 Plan: if applicable
    • Therapy Reports: Speech, Occupational therapy, Psychology reports, previous ABA reports. (if applicable) 

    The form contains the following sections:

    1. Basic Patient Information
    2. Health and Developmental History
    3. Household Information
    4. Educational History
    5. Current Concerns
    6. Child's Current Skills

    Your proactive approach to providing comprehensive background information helps us tailor our services to meet your child's specific needs effectively. We appreciate your cooperation and look forward to supporting your child's growth and development. 


    We appreciate your cooperation and look forward to supporting your child's growth and development. If you have any questions or require assistance during this process, please don't hesitate to reach out.


    Warm regards,


    The ABA Team @ Compass Center, Inc.
    Email | info-aba@compasscenterinc.com
    Phone | (818) 208-0164
    Fax | (855) 621-8966
    Compass Center, Inc.
    compasscenterinc.com/ 

  • Patient information

    All questions contained in this questionnaire are strictly confidential and will become part of your child’s records at Compass Center Inc. Please have you insurance card ready to upload, and any other developmental documents (IEP, Diagnostic Reports, PT/OT/SLP/ ABA Reports)
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  • Insurance / Funding Source Information

    In order to verify eligibility and benefits, please upload the insurance cards for the insurance providers for your child.

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  • Health and Developmental History

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  • Household Information

    Please fill out information regarding the home environment

  • Educational History

    Please fill out information according to your child's education circumstance

  • Current Educational History

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  • Previous Educational History

  • Current Concerns

    In the following section, you will first select ALL your areas of concern.

  • IMPORTANT: In the following section, you will list your top 3 areas that concern you most about your child. For each section, select one area of concern at a time and answer the questions that describe that specific concern.

  • Click "Next" to continue

  • PRIMARY CONCERN

  • SECONDARY CONCERN

  • THIRD CONCERN

  • Child's Current Skills

    Check all skills that most closely describe your child. Select ALL that apply.

  • Language Skills

  • Learning Readiness

  • Self-Care

  • Eating

  • Occupational/Fine Motor Skills

  • Recreational Activities

  • Social Activities

  • Academic Skills

  • Behavior

    My child engages in...

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  • Please sign below and click "Submit" to send our team your forms. 

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