Spectra Gymnastics
ABA Intake
Client Name
*
First Name
Last Name
Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Primary Caregiver
*
First Name
Last Name
Relationship to Client
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Guarantor if different from Primary Care Giver
First Name
Last Name
Address Same as Client
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Primary Insurance Company Name
*
Policy ID/ Group #
*
Policy Subscriber
*
First Name
Last Name
Subscriber Date of Birth
*
-
Month
-
Day
Year
Date
Primary Card Front and Back
*
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Secondary Insurance Company Name
Policy ID/ Group #
Policy Subscriber
First Name
Last Name
Subscriber Date of Birth
-
Month
-
Day
Year
Date
Secondary Card Front and Back
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Does client currently have an ASD diagnosis?
Yes
No
Is client currently receiving ABA services?
*
Yes
No
If currently receiving ABA services, about how many hours a week?
Please Select
0-10
10-15
15-20
20-30
30+
Client is interested in (click all that apply).
In Home
Clinic Location
Community
Group
Day(s) of the week client is available for ABA sessions. (Choose all that apply).
Monday
Tuesday
Wednesday
Thursday
Friday
Times of day client is available for ABA sessions. These times just give the clinic scheduler an idea of when the client is available. (Choose all that apply).
8a-10a
10a-12p
12p-2p
2p-4p
4p-6p
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We will need you to upload a copy of the diagnostic report from your referring provider.
Diagnostic Report & any other pertinent reports you would like to share with the BCBA.
*
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Client is available to start services...
*
Additional Info if needed
Today's Date
-
Month
-
Day
Year
Date
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Submit
Should be Empty: