HIPAA Soar Intake Questionnaire Form

Intake Questionnaire
Please complete the following intake questionnaire. Also, feel free to add any additional information or attach reports that you think may help allow us to get to know your child. This information is helpful when developing an initial understanding of your child’s needs and provides critical information for us to discuss with your insurance company to get authorization for services.
General Information
Name of Person Completing this Form*
Relationship to Child*
Child’s Name*
Date of Birth*

MonthDayYear
Date
Age*
Parent/Guardian Contact Information
Parent/Guardian #1*
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Occupation*
Parent/Guardian #2
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Occupation
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone (If Applicable)
Please enter a valid phone number.
Languages Spoken in the Home
Medical Information
Primary Physician
Practice Name
Phone Number
Please enter a valid phone number.
Does your child currently have a diagnosis?*

YesNo
Diagnosis
Diagnosing Physician
Date of Diagnosis

MonthDayYear
Date
Diagnosis
Diagnosing Physician
Date of Diagnosis

MonthDayYear
Date
Diagnosis
Diagnosing Physician
Date of Diagnosis

MonthDayYear
Date
Previous & Current Private Services
Does your child currently or have they ever received ABA services?*

YesNo
Service Provider
Duration (e.g., 30 minutes)
Frequency (e.g., 5x/week)
Dates
Service Provider
Duration (e.g., 30 minutes)
Frequency (e.g., 5x/week)
Dates
Service Provider
Duration (e.g., 30 minutes)
Frequency (e.g., 5x/week)
Dates
Does your child currently or have they ever received related services in a private setting?*

YesNo
Service (e.g., Speech, OT, etc.)
Duration (e.g., 30 minutes)
Frequency (e.g.,5x/week)
Dates
Service (e.g., Speech, OT, etc.)
Duration (e.g., 30 minutes)
Frequency (e.g.,5x/week)
Dates
Service (e.g., Speech, OT, etc.)
Duration (e.g., 30 minutes)
Frequency (e.g.,5x/week)
Dates
Insurance
Primary Insurance
Policy Holder
Date of Birth
Relationship to Child
Policy #
Group #
ID #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Primary Insurance
Policy Holder
Date of Birth
Relationship to Child
Policy #
Group #
ID #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Documents
Front & Back of Insurance Holder’s Driver’s License

Cancelof
Front & Back of Insurance Card(s)

Cancelof
If applicable:
Diagnosing Physician Report

Cancelof
Related Service Reports (e.g.,speech,OT,etc.)

Cancelof
Individualized Education Plan (IEP)

Cancelof
Behavior Plan

Cancelof
504 Plan

Cancelof
Medicaid FFS: FA-11F Form - Completed by Diagnosing Physician

Cancelof
Medicaid FFS: FA-29A Form – Signed by Parent/Guardian When Switching Clinics

Cancelof
Should be Empty:

Intake Questionnaire

General Information

Parent/Guardian Contact Information

Medical Information

Previous & Current Private Services

Insurance

Documents