Client Intake Form

Today's Date

MonthDayYear
Date
Child's Full Name
Child's Date of Birth

MonthDayYear
Date
Child's Age
Preferred Service Location(s)

Other
Family's Address

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Full Name
Parent/Guardian Relationship to Child
Preferred Language
Cell Phone Number
By providing your phone number, you consent to receiving text messages and calls related to scheduling, services, and updates. Standard messaging rates may apply.Format: (000) 000-0000.
Home/ALT Number
By providing your phone number, you consent to receiving text messages and calls related to scheduling, services, and updates. Standard messaging rates may apply.Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Is the child enrolled in school/preschool?
Name of school/preschool:
Availability

Please enter the anticipated availability for sessions on a consistent basis:
Mondays:
Mondays (Specific):

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Tuesdays:
Tuesdays (Specific):

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Wednesdays:
Wednesdays (Specific):

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Thursdays:
Thursdays (Specific):

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Fridays:
Fridays (Specific):

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Saturdays:
Saturdays (Specific):

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Insurance / Funding Source
Please indicate funding source:
Member/Subscriber ID
Blue Shield ABA Recommendation Form (TO BE COMPLETED BY M.D. ONLY)
Anthem ABA Recommendation Form (TO BE COMPLETED BY M.D. ONLY)
Health Net ABA Recommendation Form (TO BE COMPLETED BY M.D. ONLY)
NOTE:

Medi-Cal Members:
- Must submit a psychological evaluation presenting ASD as a diagnosis (conducted within the last 2 years) OR a copy of the signed doctor ABA Recommendation form (varies per plan)
PPO/HMO (NON Medi-Cal) Members:
- Must submit a psychological evaluation presenting ASD as a diagnosis
Upload Front & Back of Insurance Card

Cancelof
Upload Psychological Evaluation or ABA Recommendation Form

Cancelof
Current Diagnoses

Other
Behaviors

Other
Areas of Concern

Other
How did you hear about us?
General Notes / Comments:
Intake Filled By
Staff Name:
Please verify that you are not a robot
Should be Empty:

Availability