• Client Background

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Medical Information

  • Disclaimer: Without a diagnosis of Autism Spectrum Disorder or Down Syndrome, most common insurances will not cover the cost of ABA services. If your child does not currently have one of these diagnoses, we recomend you reach out to your pediatrician and request and official Autism evaluation before pursuing ABA services. 

  • A diagnosis of Autism Spectrum Disorder is usually necessary to receive clinical ABA services. Has the child been diagnosed with Autism Spectrum Disorder?
  • If your child has not received a diagnosis of Autism Spectrum Disorder, are they scheduled to be assessed to receive a diagnosis?
  • A diagnosis of Down Syndrome may also be approved by insurance to qualify for ABA services. Has your child been diagnosed with Down Syndrome?
  • Has the child been diagnosed with any other developmental disabilities?
  • Date of Initial Diagnosis of ASD or Down Syndrome.
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
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  • Has the child previously received a recommendation for Applied Behavior Analysis services from a pediatrician/psychiatrist?
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  • Has the child previously received ABA services?

  • Insurance Information

  • Does the child have medical insurance?
  • Effective Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Termination Date
     - -
    2 digit month, 2 digit day, 4 digit year
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  • Does the child have supplemental medical insurance?
  • Effective Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Termination Date
     - -
    2 digit month, 2 digit day, 4 digit year
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  • Educational Information

  • Does the child attend school?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Does the child have an Individualized Education Plan?
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  • Date child started school
     - -
    2 digit month, 2 digit day, 4 digit year

  • Additional Information

  • Should be Empty: