Pre-Intake Questionnaire
This must be completed before starting the intake process. For questions, please email Katy Hathorn: khathorn@laholyangels.org or call 318-797-8500.
Documents needed
Diagnostic Evaluation
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Prescription for ABA Services - this can be obtained from your child's pediatrician
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Insurance Card(s) – copy of FRONT and BACK of ALL insurance cards
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Child's Personal Information
Name
*
First Name
Middle Name
Last Name
Suffix
DOB
*
Gender
*
Please Select
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian 1
Is Parent 1 the legal guardian?
*
Yes
No
Name
*
First Name
Middle Name
Last Name
Suffix
DOB
*
Relationship to child
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is Parent 1’s address the same as child’s? Yes or No - if no, fill in below
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email for Parent/Guardian 1
*
example@example.com
Email for Parent/Guardian 1
*
example@example.com
Parent/Guardian 2
Is Parent 2 the legal guardian?
Yes
No
Name
First Name
Middle Name
Last Name
Suffix
DOB
Relationship to child
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is Parent 2’s address the same as child’s? Yes or No - if no, fill in below
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Occupation
Email for Parent/Guardian 2
*
example@example.com
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Diagnostic Information
What is your child's primary diagnosis?
*
Secondary Diagnosis?
*
Date your child was first diagnosed?
*
Licensed Mental Health Professional / Physician who gave diagnosis
*
Agency Name
*
Date of Last Evaluation (include copy of evaluation):
*
Upload Evaluation
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Insurance Information
Name of Primary Insurance Company
*
Name of Secondary Insurance Company
*
If not on Medicaid, are parents aware of TEFRA act?
*
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Submit
Should be Empty: