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Initial Intake Questionnaire

Let us know how we can help you!
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber Contact

First NameLast Name
Subscriber Date Of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Is your child attending school in person?
Are you open to withdrawing your child from school for ABA services?
Choose the school type.
Has your child been diagnosed with ASD (Autism)?
Could you provide a medical professional’s report diagnosing your child?
Please provide a copy of the ASD diagnosis report, issued by a physician or psychologist.

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Primary Insurance Company
(type name of the insurance company)
Primary Insurance Policy Number
Member ID
Secondary Insurance Company
Secondary Insurance Policy Number
Please provide a copy of Insurance Cards (Front)

Cancelof
Please provide a copy of Insurance Card (Back)

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We offer services at both in-home and in-school, providing comprehensive options and increased appointment availability. Kindly indicate your preferred location for our services.
Preferred location for services.
Feel free to add any additional comments in the section below.
By submitting this form you agree to receive SMS text messages from Artistic Legends LLC. You can reply "STOP" at any time to 678.597.4422 to stop receiving messages. Our "SMS" Texting Terms & Privacy" are available at https://artisticlegendsaba.com/privacy-policy/
Thank you for your interest in Artistic Legends ABA; expect hear from us within a few days.
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Initial Intake Questionnaire