Brightview Care Client Registration Form

Dear Parents and Caregivers,

Welcome to Brightview Care! We are thrilled that you are considering our program for your child and are excited to partner with you in supporting your family. At Brightview Care, we offer home-based Applied Behavior Analysis (ABA) therapy tailored to children with Autism Spectrum Disorder (ASD) and related conditions. Our mission is to provide high-quality, compassionate care to every child we work with, and we are committed to meeting the unique needs of each family.

To begin the enrollment process, we kindly ask that you complete the required paperwork for your child. Please take your time to fill out the client intake form in full, ensuring that all sections are completed. Once the packet is finished, simply click the "continue" button and sign at the bottom. Along with the completed application, we will need a copy of all relevant medical documentation, including a neuropsychological evaluation that supports the autism diagnosis, as well as a copy of your child’s insurance card.

Once we receive your completed form, we will reach out to guide you through the next steps of the intake process. If you have any questions or need assistance at any point, please don't hesitate to contact us.

Thank you once again for your interest in Brightview Care—we look forward to the opportunity to support your child and family.

Warm regards,
Admissions Team
Brightview Care

Client Legal Name:

Name Client Goes by:

Age:

Gender:

Date of Birth:

Primary Language:

Home Address:

City:

State:

Zip:

Name of School:

Grade:

Teacher's Name:

Is the client receiving or has the client received special services or accommodations at school?

YesNo

If yes, please explain what type: (e.g. IEP, IFSP, 504 Plan)

Client lives with (who lives in the house)?

Are both parents aware of services being sought at Brightview Care?

YesNoOther

Foster or Adoptive Family?

YesNo

Name Parent/Caregiver 1

Relationship

Home Address

City

State

Zip

Cell Phone

Home Phone

Email Address

example@example.com

Employed by

Occupation

Name Parent/Caregiver 2

Relationship

Home Address

City

State

Zip

Cell Phone

Home Phone

Email Address

example@example.com

Employed by

Occupation

Emergency Contact:

Relationship to Client:

Cell Phone Number:

I authorize Brightview Care to make any emergency decisions deemed necessary for the care and safety of my child while they are at the service location.

Reason for seeking ABA Services? Please explain.

Primary Method of Communication (leading others, voice, AAC, sign, etc)

Client Preferences (favorite activities food interests, topics, sensory items):

Client Dislikes (aversions):

Client Strengths:

Maladaptive (Problem) Behaviors to Reduce:

Please check off any of the following behaviors that your child may engage in:

Has the client had ABA therapy in the past?

YesNo

What was the name of the agency?

During which dates did the client receive services?

What was the reason for termination of services?

Please list any other services that the client currently receives. (Speech, OT, PT, feeding therapy, etc.) Please also list the days and times the client attends the therapy sessions.

Diagnosis:

Client's Primary Physician:

Hospital Clinic Preference:

Do we have permission to contact the doctor?

YesNo

Medicaid Policyholder:

Policyholder Birthday:

Date

Allergies:

Please list any medications your child is taking the purpose of the medication dosage and any concerns:

List any medical restrictions to clients activities:

Known Dietary Restrictions:

History of Seizures?

YesNo

I understand that in certain medical situations, the staff may need to contact local emergency services prior to reaching the Parent/Caregiver, child's physician, or another adult designated by the Parent/Caregiver.

YesNo

Please note that ABA is most effective with a minimum of 10 hours of ABA therapy per week and 1 hour of caregiver training.

Check each time that you are available for ABA services:

	Morning	Afternoon	Evening	Any time	Not available	Morning and Afternoon	Afternoon and Evening
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays

Notes/Concerns:

Brightview Care Client Intake Form

SCHOOL INFORMATION

FAMILY INFORMATION

EMERGENCY CONTACT INFORMATION

CAREGIVER CONCERNS

HISTORY OF SERVICES/ADDITIONAL SERVICES

MEDICAL INFORMATION

AVAILABILITY

INSURANCE INFORMATION