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)*

Center (Glendale Office)Center (Santa Clarita Office)HomeSchool/PreschoolOther
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*
Home/ALT Number
Parent/Guardian Email*
example@example.com
Is the child enrolled in school/preschool?*

YesNo
Name of school/preschool:
Availability

Please enter the anticipated availability for sessions on a consistent basis:
Mondays:*

Open / Available Full DayClosed / Not Available Full DayAvailable for Specific Hours
Mondays (Specific):*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Tuesdays:*

Open / Available Full DayClosed / Not Available Full DayAvailable for Specific Hours
Tuesdays (Specific):*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Wednesdays:*

Open / Available Full DayClosed / Not Available Full DayAvailable for Specific Hours
Wednesdays (Specific):*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Thursdays:*

Open / Available Full DayClosed / Not Available Full DayAvailable for Specific Hours
Thursdays (Specific):*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Fridays:*

Open / Available Full DayClosed / Not Available Full DayAvailable for Specific Hours
Fridays (Specific):*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Saturdays:*

Open / Available Full DayClosed / Not Available Full DayAvailable for Specific Hours
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*

Autism (ASD)ADD/ADHDCerebral PalsyDown SyndromeEmotional Disorder (ED)Intellectual Disability (ID)Speech DelayNO DIAGNOSISOther
Behaviors*

TantrumsSelf-Stimulatory BehaviorProperty DestructionSelf-Injurious BehaviorsAggressionOther
Areas of Concern*

Social SkillsPotty TrainingSpeech/Communication DelayPlay SkillsChanges to RoutineFeedingOther
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