ABA Therapy Initial Intake Form (Compass Center, Inc.) | ENGLISH Form
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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)
  • Date of Birth*
     - -
  • Gender*
  • Format: (000) 000-0000.
  • Date of last physical exam
     - -

  • 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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  • Check all the developmental areas concerns or problems that have brought you to Compass Center, Inc.
  • What services are you seeking from Compass Center, Inc.?*
  • How did you hear about us?*

  • Health and Developmental History

  • Rows
  • Did you Child have any childhood illnesses? (select ALL that Apply)*
  • Does your child use a wheelchair or walker?
  • Is there a family history of mental illness or disabilities?*

  • Household Information

    Please fill out information regarding the home environment
  • Is there an active custody agreement?*

  • Educational History

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

  • Current Educational History

  • Ever had psychological testing at school?*
  • Has an Active IEP?*
  • Did you child previously have an IEP?*
  • Has a 504 Plan?*
  • Did you child previously have a 504 Plan?*
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  • Which services is your child currently receiving at school (select ALL that apply)*
  • Rows

  • Previous Educational History

  • Attended/Participated in Early Intervention Program (before age 3)*
  • Attended pre-school? *
  • Attended kindergarten? *
  • Was your child previous in any special class?*
  • Ever suspended / expelled?*

  • Current Concerns

    In the following section, you will first select ALL your areas of concern.
  • Select ALL the Current Behaviors of Concern*
  • How severe is the impact of your child's behavior on your daily life and the lives of those around him/her? Select from 1 to 5. 1 being the lowest and 5 the highest (severity scale).*
  • Is your child a danger to himself or others?*
  • Does your child have any of the following behaviors that have recently caused harm to self, others or property?*
  • Does your child use his/her strength to overpower others?*
  • Should we have additional assistance during the assessment for behaviors 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

  • Does anyone else in your family have a similar challenge?*
  • What treatments has your child received for this concern or problem?*
  • Was any treatments effective at reducing problem?*
  • Do you have an additional area of concern?*

  • SECONDARY CONCERN

  • Does anyone else in your family have a similar challenge?*
  • What treatments has your child received for this concern or problem
  • Were any treatments effective at reducing problem?
  • What is the SECONDARY area of concern
  • Do you have an additional area of concern?*

  • THIRD CONCERN

  • Does anyone else in your family have a similar challenge?*
  • What treatments has your child received for this concern or problem
  • Were any treatments effective at reducing problem?

  • Child's Current Skills

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

  • Language Skills

  • My child is able to...

  • Learning Readiness

  • Eye Contact: My child...
  • Appropriate Sitting (sits correctly in chair): My child...
  • Simple Directions: My child responds consistently to...

  • Self-Care

  • Toileting: My child...
  • Dressing: My child...
  • Bathing/Washing: My child...

  • Eating

  • My child...

  • Occupational/Fine Motor Skills

  • My child is able to correctly do/use...

  • Recreational Activities

  • My child enjoys...

  • Social Activities

  • My child has exposure to other children through...

  • Academic Skills

  • My child is able to...

  • Behavior

    My child engages in...

  • Self-stimulatory behavior
  • Self-injurious behavior
  • Aggressive/highly disruptive behavior
  • Date*
     - -

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

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