ABA Therapy Request
Please fill out the following form to the best of your abilities to help guide our intake and waitlist process. A member of our team will be in contact with you within 48 business hours of your request for services to provide you with more information.
Important Note Before You Begin
We encourage you to scroll through the entire document and note what information and files you will need to submit this request, as it will not save if you have to step away from it. Please complete in its' entirety and submit all in one sitting. Also, note that we require copies of the patient's insurance card, most recent physical (or KBH if Kansas Medicaid), and IEP/504 as applicable. If you do not submit these documents with your request we will be unable to add you to the waitlist! Please make sure you gather these prior to starting the form.
Client Demographic Information
Please provide as much information as possible to help guide the initial steps of the therapy process. Thank you!
Name of Individual Completing the Form
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First Name
Last Name
Who are you filling the form out for?
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My child
Myself
Another adult in my legal custody
Other
Contact Email Address
*
We highly utilize email to communicate during the treatment process. Please provide us with the best email address to contact you at regarding paperwork, scheduling, and treatment progress.
Child/Adult's Legal Name
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First Name
Last Name
Child/Adult's Date of Birth
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-
Month
-
Day
Year
Date
If filling out for a minor child, is the child adopted or in foster care?
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Yes
No
N/A
Child/Adult's Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Phone Number
*
Please enter a valid phone number.
Child/Adult's Birth Sex
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Child/Adult's Gender
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Child/Adult's Pronouns
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Child/Adult's Race/Ethnicity
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Child/Adult's Religion/Spirituality
*
ABA Therapy Services
What diagnosis are you seeking ABA therapy for?
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Please Select
My child has a formal diagnosis of autism spectrum disorder and I have a copy of the report ready to submit.
My child has a different diagnosis or a preliminary diagnosis of autism spectrum disorder. I need to join the waitlist for autism assessment or be referred to another agency for the evaluation.
I am seeking services for an adult or for a child without a diagnosis of autism spectrum disorder and am interested in private paying for services.
Please upload their formal Autism Evaluation Report (Report should contain information/scores related to the CARS, ADOS-2, ADI-R, etc.)
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Where are you requesting services?
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In-Person at the Coffeyville Clinic Location
In-Person at the Baxter Springs Clinic Location
Telehealth Parent Coaching Services
Availability for Services- (Keeping in mind that most clients receive 10-40 hours per week of therapy, please select any/all time slots you are available for. We run our clinics in blocks, so you must be available for the entire block.)
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Monday
Tuesday
Wednesday
Thursday
Friday
8:45 am- 12:30 pm
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
12:30 pm- 4:15 pm
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Parent/Guardian Demographic Information
Please provide as much information as possible to help guide the initial steps of the therapy process. Thank you!
Legal Guardian #1 Legal Name
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First Name
Last Name
Relationship to Client
*
Please Select
Mother
Father
Grandparent
Other Family Member
Legal Guardian
Legal Guardian #1 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Legal Guardian #1 Phone Number
*
Please enter a valid phone number.
Legal Guardian #1 Email Address
*
We highly utilize email to communicate with caregivers throughout the therapy process. Please provide us with the best email address to contact you at regarding paperwork, scheduling, and treatment.
Legal Guardian #1 Marital Status
*
Legal Guardian #1 Marital Status
*
Legal Guardian #1 Education Level
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Please Select
Some High School
High School Diploma or GED
Some College
Associates Degree
Bachelor's Degree
Advanced Degree (anything beyond a Bachelor's)
Do you or your child/adult have another legal guardian responsible for making their medical decisions? If so, please provide that information below. If they do not have other legal guardians, you may indicate so in the drop-down and proceed on to the next section.
*
Please Select
Yes- There is another guardian
No- I am the only guardian
Legal Guardian #2 Legal Name
First Name
Last Name
Relationship to Client
Please Select
Mother
Father
Grandparent
Other Family Member
Legal Guardian
Legal Guardian #2 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Legal Guardian #2 Phone Number
Please enter a valid phone number.
Legal Guardian #2 Email Address
We highly utilize email to communicate with caregivers throughout the therapy process. Please provide us with the best email address to contact you at regarding paperwork, scheduling, and treatment.
Legal Guardian #2 Marital Status
Legal Guardian #2 Education Level
Please Select
Some High School
High School Diploma or GED
Some College
Associates Degree
Bachelor's Degree
Advanced Degree (anything beyond a Bachelor's)
Insurance Information
Please provide all relevant insurance information for your child/adult below. Failure to submit the accurate, current cards may result in a delay in services and/or the client being responsible the cost of services.
Name of Insurance Provider
*
Please Select
Blue Cross Blue Shield
Kansas Medicaid- Healthy Blue
Kansas Medicaid- Sunflower
Kansas Medicaid- UHC
Oklahoma Medicaid SoonerCare - No MCO
Oklahoma Medicaid - Aetna
Oklahoma Medicaid - Humana
Oklahoma Medicaid - OK Complete
Other insurance (client would self-pay for services)
Name of Policy Holder (Note: This will be the child/adult for Medicaid, but may be the parent/guardian for BCBS)
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First Name
Last Name
Policy Holder Social Security Number (Note: This will be the child/adult for Medicaid, but may be the parent/guardian for BCBS)
*
Enter the Social Security Number W/Dashes here.
Policy Holder Date of Birth
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-
Month
-
Day
Year
Date
Member Identification Number
*
Found on the front of the insurance card.
Member Group ID Number
*
Found on the front of the insurance card.
Please upload a copy of the front of your child's current insurance card.
*
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Please note, you will not be added to the waitlist without a clear copy of the insurance card.
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Please upload a copy of the back of your child's current insurance card.
*
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Please note, you will not be added to the waitlist without a clear copy of the insurance card.
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Do you or your child/adult have secondary coverage? (i.e. Medicaid and Private Insurance.) If so, please provide that information below. If you do not have secondary coverage, you may indicate so in the drop-down and proceed on to the next section. Please note, failure to report secondary insurance information may result in being responsible for the cost of services.
*
Please Select
No Secondary Insurance Coverage
My Secondary Insurance Isn't Listed
Blue Cross Blue Shield
Kansas Medicaid- Aetna
Kansas Medicaid- Sunflower
Kansas Medicaid- UHC
Name of Policy Holder (Note: This will be the child/adult for Medicaid, but may be the parent/guardian for BCBS)
First Name
Last Name
Policy Holder Social Security Number (Note: This will be the child/adult for Medicaid, but may be the parent/guardian for BCBS)
Enter the Social Security Number W/Dashes here.
Policy Holder Date of Birth
-
Month
-
Day
Year
Date
Member Identification Number
Found on the front of the insurance card.
Member Group ID Number
Found on the front of the insurance card.
Please upload a copy of the front of your child's current secondary insurance card.
Browse Files
Drag and drop files here
Choose a file
Please note, you will not be added to the waitlist without a clear copy of the insurance card.
Cancel
of
Please upload a copy of the back of your child's current secondary insurance card.
Browse Files
Drag and drop files here
Choose a file
Please note, you will not be added to the waitlist without a clear copy of the insurance card.
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Family History Information
Please fill out the following section with as much information as possible.
Who currently lives at home with the child or adult? (Include sibling names and ages, please.)
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What languages are spoken in the home?
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Do either of the biological parents have any known physical, mental, or learning disabilities? If so, please list who it is and what the condition is.
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Is there anything else about the child or adult's family that you would like for us to know?
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Developmental History Background
Please provide as much information about the child or adult's developmental background as possible.
Pregnancy and Delivery
Where there any of the following concerns during the pregnancy?
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Medical Concerns
Requirement for a Special Diet
Medications
Pre-Term Birth
Accident or Injuries
Other
N/A
If you selected any concerns in the previous section, please provide detailed information on those concerns.
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Age of biological mother at time of birth.
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Any post-birth needs for mother or child (oxygen, extended stay, surgery, NICU, etc.)? If so, what were those needs?
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Early Childhood Development
Select any of the following developmental milestones that the child or adult were delayed in demonstrating or missed entirely.
Typical Two Month Milestones
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Calms down when spoken to or picked up
Looks at your face
Seems happy to see you when you walk up to them
Smiles when you talk to or smile at them
Makes sounds other than crying
Reacts to loud sounds
Watches you as you move
Looks at a toy for several seconds
Holds head up when on tummy camera
Moves both arms and both legs
Opens hands briefly
Typical Four Month Milestones
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Smiles on their own to get your attention
Chuckles (not yet a full laugh) when you try to make them laugh
Looks at you, moves, or makes sounds to get or keep your attention
Makes sounds like “oooo”, “aahh” (cooing)
Makes sounds back when you talk to them
Turns head towards the sound of your voice
If hungry, opens mouth when they see breast or bottle
Looks at their hands with interest
Holds head steady without support when you are holding them
Holds a toy when you put it in their hand
Uses their arm to swing at toys
Brings hands to mouth
Pushes up onto elbows/forearms when on tummy
Typical Six Month Milestones
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Knows familiar people
Likes to look at self in a mirror
Laughs
Takes turns making sounds with you
Blows “raspberries” (sticks tongue out and blows)
Makes squealing noises
Puts things in their mouth to explore them
Reaches to grab a toy they want
Closes lips to show they don't want more food
Rolls from tummy to back
Pushes up with straight arms when on tummy
Leans on hands to support themselves when sitting
Typical 9 Month Milestones
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Is shy, clingy, or fearful around strangers
Shows several facial expressions, like happy, sad, angry, and surprised
Looks when you call their name
Reacts when you leave (looks, reaches for you, or cries)
Smiles or laughs when you play peek-a-boo
Makes a lot of different sounds like “mamamama” and “bababababa”
Lifts arms up to be picked up
Looks for objects when dropped out of sight (like a spoon or toy)
Bangs two things together
Gets to a sitting position by themselves
Moves things from one hand to their other hand
Uses fingers to “rake” food towards themselves
Sits without support
Typical 12 Month Milestones
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Plays games with you, like pat-a-cake
Waves “bye-bye”
Calls a parent “mama” or “dada” or another special name
Understands “no” (pauses briefly or stops when you say it)
Puts something in a container, like a block in a cup
Looks for things they see you hide, like a toy under a blanket
Pulls up to stand
Walks, holding on to furniture
Drinks from a cup without a lid, as you hold it
Picks things up between thumb and pointer finger, like small bits of food
Typical 15 Month Milestones
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Copies other children while playing, like taking toys out of a container when another child does
Shows you an object they like
Claps when excited
Hugs stuffed doll or other toy
Shows you affection (hugs, cuddles, or kisses you)
Tries to say one or two words besides “mama” or “dada,” like “ba” for ball or “da” for dog
Looks at a familiar object when you name it
Follows directions given with both a gesture and words. For example, they give you a toy when you hold out your hand and say, “Give me the toy.”
Points to ask for something or to get help
Tries to use things the right way, like a phone, cup, or book
Stacks at least two small objects, like blocks
Takes a few steps on his own
Uses fingers to feed herself some food
Typical 18 Month Milestones
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Moves away from you, but looks to make sure you are close by
Points to show you something interesting
Puts hands out for you to wash them
Looks at a few pages in a book with you
Helps you dress them by pushing arm through sleeve or lifting up foot
Tries to say three or more words besides “mama” or “dada”
Follows one-step directions without any gestures, like giving you the toy when you say, “Give it to me.”
Copies you doing chores, like sweeping with a broom
Plays with toys in a simple way, like pushing a toy car
Walks without holding on to anyone or anything
Scribbles
Drinks from a cup without a lid and may spill sometimes
Feeds themselves with their fingers
Tries to use a spoon
Climbs on and off a couch or chair without help
Typical 2 Year Milestones
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Notices when others are hurt or upset, like pausing or looking sad when someone is crying
Looks at your face to see how to react in a new situation
Points to things in a book when you ask, like “Where is the bear?”
Says at least two words together, like “More milk.”
Points to at least two body parts when you ask them to show you
Uses more gestures than just waving and pointing, like blowing a kiss or nodding yes
Holds something in one hand while using the other hand; for example, holding a container and taking the lid off
Tries to use switches, knobs, or buttons on a toy
Plays with more than one toy at the same time, like putting toy food on a toy plate
Kicks a ball
Runs
Walks (not climbs) up a few stairs with or without help
Eats with a spoon
Typical 30 Month Milestones
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Plays next to other children and sometimes plays with them
Shows you what they can do by saying, “Look at me!”
Follows simple routines when told, like helping to pick up toys when you say, “It’s clean-up time.”
Says about 50 words
Says two or more words together, with one action word, like “Doggie run”
Names things in a book when you point and ask, “What is this?”
Says words like “I,” “me,” or “we”
Uses things to pretend, like feeding a block to a doll as if it were food
Shows simple problem-solving skills, like standing on a small stool to reach something
Follows two-step instructions like “Put the toy down and close the door.”
Shows they know at least one color, like pointing to a red crayon when you ask, “Which one is red?”
Uses hands to twist things, like turning doorknobs or unscrewing lids
Takes some clothes off by themselves, like loose pants or an open jacket
Jumps off the ground with both feet
Turns book pages, one at a time, when you read to them
Typical 3 Year Milestones
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Calms down within 10 minutes after you leave them, like at a childcare drop off
Notices other children and joins them to play
Talks with you in conversation using at least two back-and-forth exchanges
Asks “who,” “what,” “where,” or “why” questions, like “Where is mommy/daddy?”
Says what action is happening in a picture or book when asked, like “running,” “eating,” or “playing”
Says first name, when asked
Talks well enough for others to understand, most of the time
Draws a circle, when you show them how
Avoids touching hot objects, like a stove, when you warn them
Strings items together, like large beads or macaroni
Puts on some clothes by themselves, like loose pants or a jacket
Uses a fork
Typical 4 Year Milestones
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Pretends to be something else during play (teacher, superhero, dog)
Asks to go play with children if none are around, like “Can I play with Alex?”
Comforts others who are hurt or sad, like hugging a crying friend
Avoids danger, like not jumping from tall heights at the playground
Likes to be a “helper”
Changes behavior based on where they are (place of worship, library, playground)
Says sentences with four or more words
Says some words from a song, story, or nursery rhyme
Talks about at least one thing that happened during their day, like “I played soccer.”
Answers simple questions like “What is a coat for?” or “What is a crayon for?”
Names a few colors of items
Tells what comes next in a well-known story
Draws a person with three or more body parts
Catches a large ball most of the time
Serves themselves food or pours water, with adult supervision
Unbuttons some buttons
Holds crayon or pencil between fingers and thumb (not a fist)
Typical 5 Year Milestones
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Follows rules or takes turns when playing games with other children
Sings, dances, or acts for you
Does simple chores at home, like matching socks or clearing the table after eating
Tells a story they heard or made up with at least two events. For example, a cat was stuck in a tree and a firefighter saved it
Answers simple questions about a book or story after you read or tell it to them
Keeps a conversation going with more than three back-and-forth exchanges
Uses or recognizes simple rhymes (bat-cat, ball-tall)
Counts to 10
Names some numbers between 1 and 5 when you point to them
Uses words about time, like “yesterday,” “tomorrow,” “morning,” or “night”
Pays attention for 5 to 10 minutes during activities. For example, during story time or making arts and crafts (screen time does not count)
Writes some letters in their name
Names some letters when you point to them
Buttons some buttons
Hops on one foot
Do you have any concerns with your child's sleeping or eating? If so, what are those concerns? For adult clients, were there concerns with your sleeping or eating patterns as a child? Are they still occurring today?
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Is there anything else regarding the child or adult's developmental history that you'd like us to know?
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Medical History
Please provide as much information as possible about the child or adult's medical history and current health status. Ruling out medical causes for certain symptoms is highly important in the treatment process.
Name of Primary Care Physician
*
First Name
Last Name
Primary Care Physician Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Care Physician Phone Number
*
Please enter a valid phone number.
Date of Last Physical Exam/Wellness Check
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-
Month
-
Day
Year
Date
Copy of Current Physical (Note: Individuals under the age of 21 applying for ABA services must have their physical on an official KanBeHealthy Physical Form per insurance requirements.)
*
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Note: Failure to provide a clear, legible physical form dated within the last 365 days will result in a delay in being placed on the waitlist for services. Please call 620-330-9036 to have the form emailed to you prior to talking with your doctor.
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Does the child or adult have any allergies? If so, what are they?
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Has the child or adult had any significant illnesses, hospitalizations, or surgeries? If so, please explain.
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Please list all of the child or adult's current medications, including name, dosage, time(s) of day given, purpose of the medication, and who prescribed the medication. Write N/A in the top row if they are not on medications.
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Medication Name
Dosage
Time of Day Given
Purpose of Medication
Who prescribed the medication?
When was the med first prescribed?
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
If you ran out of room above, please continue to list the child or adult's medication information below.
Does the child or adult have any history of infectious diseases or other diagnoses we should know about?
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Does the child or adult have a history of seizures? Please include the type and current treatment if so.
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Educational History
Providing information about the child or adult's educational history helps to provide background information needed for treatment planning. If the field does not pertain to the individual at this time, please write N/A.
Does the child or adult attend school?
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Yes
No
Name of School
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What grade is the child or adult in?
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Name of Teacher
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First Name
Last Name
Did/Does the child or adult have an IEP/504 plan?
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Yes
No
Anything else you would like us to know about the child or adult's educational or school history?
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Please upload the child or adult's most recent/current IEP/504 plan.
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Therapy History
Please provide us with as much detail as you can surrounding the mental health, ABA, speech, OT, PT, or other relevant therapeutic services that the child or adult has received. If they have received ABA therapy prior to this request, we will request a copy of their most recent treatment plan or a release of information to obtain that report from the provider.
Has the child or adult received mental health services in the past, including previous assessments?
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Yes
No
If yes, please provide the name of the provider and the service the child or adult received.
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Has the child or adult received ABA therapy services in the past, including parent coaching services?
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Yes
No
If yes, please provide the name of the provider and the service the child or adult received.
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Does the child or adult receive speech, occupational therapy, physical therapy? Have they received them in the past? (If no, please skip the provider section below.)
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Yes- Currently Receiving Services
Received Services in Past
No- Have Never Received These Services
Which therapy has the child or adult received?
Speech
Occupational Therapy
Physical Therapy
Name of Provider (Speech)
First Name
Last Name
Provider Address (Speech)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (Speech)
Please enter a valid phone number.
Name of Provider (Occupational Therapy)
First Name
Last Name
Provider Address (Occupational Therapy)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (Occupational Therapy)
Please enter a valid phone number.
Name of Provider (Physical Therapy)
First Name
Last Name
Provider Address (Physical Therapy)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (Physical Therapy)
Please enter a valid phone number.
Is there anything else you'd like our team to know about the child or adult's therapy history?
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Current Behavioral Concerns
Please provide us with information on barrier behaviors that the child or adult has engaged in in the previous six month period.
Please select if the child or adult currently engages in the behavior or has engaged in the behavior in the last six months:
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Physical Aggression Toward Others (hitting, kicking, biting, punching, scratching, etc.)
Self-Injurious Behavior (hitting self, biting self, headbanging, pulling teeth, etc.)
Property Destruction
Elopement
Sensory Concerns
Tantrums
Screaming/Yelling/Loud Vocalizations
Other
N/A
Are there any other behavioral concerns you'd like our team to know about?
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How did you hear about our services?
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Legal Guardian Consent
The information I have provided for myself, my child, or the adult is accurate and true to the best of my ability and I am legally authorized to disclose this information.
Parent/Guardian Signature
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