Intake Form for Care Providers

New Client Intake Form

Please submit a copy of your insurance card (front and back), along with any relevant clinical diagnosis paperwork at your earliest convenience. Por favor presentar una copia de la tarjeta de seguro médico (frente y reverso), junto con documentación con el diagnóstico, la fecha de el diagnóstico y mande al correo electrónico Transcendbehavioralservices@gmail.com
Patient's Name

First NameLast Name
Caregiver's name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Patient's date of birth

MonthDayYear
Contact E-mail
Insurance
Member ID
Diagnosing Provider
Date of Diagnosis
Primary Care Provider
Primary Care Provider Phone Number
Any other diagnosis

Personal History
List any major illnesses or hospitalization of patient/ cualquier enfermedad importante o hospitalización del paciente:
What medications or drugs is patient taking? Liste cualquier enfermedad importante o hospitalización del paciente?
Is patient in school? ¿ Paciente asiste a la escuela?

Has patient ever received ABA services before? “¿El paciente ha recibido previamente servicios de ABA?”
Please list any other therapies- past or present: Indique cualquier otra terapia, pasada o actual:
We are committed to ensuring that your privacy is protected. Should we ask you to provide certain information by which you can be identified when using our services be assured that it will only be used in accordance with this privacy statement.

We will not intentionally share the contents of any email or information submitted via the internet with any third party. However, due to the nature of electronic communications, we cannot and do not provide any assurances that the contents of your email will not become known or accessible to third parties. We urge you not to provide any confidential information to us via electronic communication. Should you choose to communicate via email, the provider contacted will respond to any emails sent until you request that form of communication to cease. Please take all precautions necessary to secure your email should you choose to use it to contact the provider.
Signature and Submission
Date

MonthDayYear
If patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.
Parent/Guardian Signature/Firma
Date

MonthDayYear
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