New Patient Intake Form

New Patient Intake Form

Fields marked with an asterisk (*) are required.
Patient Details:
Full Name*

First NameMiddle NameLast Name
Preferred Name:
Sex*
Date of Birth*

MonthDayYear
Date
Age*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Grade Level*
Current School*
Patient's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Demographics:
Parent/Guardian 1:
Full Name*

First NameLast Name
Relationship to Patient*
Date of Birth*

MonthDayYear
Parent/Guardian DOB
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Preferred Method of Contact*

CallTextEmail
Home Address*

Same as Patient
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Marital Status
Parent/Guardian Driver's License Number*
Front of Driver's License*

Cancelof
Back of Driver's License*

Cancelof
Parent/Guardian 2:
Full Name

First NameLast Name
Relationship to Patient
Date of Birth

MonthDayYear
Parent/Guardian DOB
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred Method of Contact

CallTextEmail
Home Address

Same as Patient
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Marital Status
Parent/Guardian Driver's License Number
Front of Driver's License

Cancelof
Back of Driver's License

Cancelof
Medical Information
Medical History
Primary Care Physician*
Physician Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last Physical Exam*

MonthDayYear
Date
Current Medications (Name and Dosage)*
Allergies*
Relevant Medical Conditions*
Previous Therapies or Interventions*
Insurance Information
Insurance Provider*
Policy Number*
Group Number*
Insurance Company Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Owner's Name*

First NameLast Name
Relationship to Patient*
Last 4 digits of Policy Owner's SSN*
Policy Owner's DOB*

MonthDayYear
Policy Owner's Employer*
Front of Insurance Card

Cancelof
Back of Insurance Card

Cancelof
Referring Physician Information
Referring Physician
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referral Documentation

Cancelof
Diagnosing Physician Information
Diagnosing Physician
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Diagnosis Report

Cancelof
Diagnosis Information
Autism Diagnosis

YesNo
Date of Autism Diagnosis

MonthDayYear
Date
Other Diagnoses
Behavioral Information
Please describe any current behavioral concerns
How long have these behaviors been occuring?
Are there any known triggers for these behaviors?
Previous behavioral interventions (if any):
Has the client had ABA services before?

YesNo
If yes, please include the ABA provider's information:
Do we have permission to obtain records?

YesNoN/A
Is the client receiving any other therapies? (Check all that apply):

Speech TherapyOccupational TherapyPhysical TherapyOther (please specify)
Is there a family history of developmental or behavioral disorders?
Any significant family events or stressors?
Treatment Goals
What are your primary goals for ABA therapy?
Are there any specific behaviors you would like to address?
Are there any skills you would like the client to develop?
Are you willing to participate in parent training?*

YesNo
Additional Notes:
If you would like to provide any additional documentation (doctor notes, treatment plans, physician information, etc.) please upload here:

Cancelof
Consent & Acknowledgement
I, the undersigned, give consent for Harmony ABA Centers to provide ABA therapy services to Patient Name .
Signature
Date

MonthDayYear
Date
Should be Empty:

New Patient Intake Form

Parent/Guardian Demographics:

Parent/Guardian 1:

Parent/Guardian 2:

Medical Information

Medical History

Insurance Information

Referring Physician Information

Diagnosing Physician Information

Diagnosis Information

Behavioral Information

Treatment Goals

Consent & Acknowledgement