Client Background

Client Background
Clients Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Parent/Guardian Full Name

First NameLast Name
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance Information
Does the child have medical insurance?
If "Yes", list insurance provider.
Member ID Number
Effective Date

MonthDayYear
Date
Termination Date

MonthDayYear
Date
Please attach a copy of their insurance card.

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Does the child have supplemental medical insurance?
If "Yes", list supplemental insurance provider.
Member ID Number
Effective Date

MonthDayYear
Date
Termination Date

MonthDayYear
Date
Please attach a copy of their supplemental insurance card.

Cancelof

Educational Information
Does the child attend school?
If so, where?
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
School Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Does the child have an Individualized Education Plan?
If "yes", please upload the document.

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Date child started school

MonthDayYear
Date
Grade

Additional Information
Briefly list areas of strengths your child has.
List any current behavioral concerns your child is displaying. Please be as thorough as possible. It is important that we are able to fully understand a client's needs to properly plan for their services.
List any relevant factors which may impact services (allergies, medical conditions, schedule conflicts, etc.)
Is there anything else we should know about your child?
Which days and times are best for weekly ABA sessions? Our clients attend sessions on either Monday, Wednesday, Friday OR Tuesday, Thursday. We are open Monday- Friday. Our sessions are either 8:00 am - 12:00 pm or 12:30 pm - 4:30 pm. Please list each day and session time which are available.
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