ABC's of Learning Therapy Intake Form
This form is HIPAA compliant to ensure your privacy and security.
Date of Contact
-
Month
-
Day
Year
Date
Recipients Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Parent/Guardian Name
First Name
Last Name
Insurance Provider
Does The Recipient Have Recent Diagnosis of Autism?
Yes
No
When Did The Recipient Receive The Diagnoses of Autism?
-
Month
-
Day
Year
Date
Who Provided The Diagnoses?
First Name
Last Name
Diagnosis Provider Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Diagnosis Provider Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do You have Copy of Psychological Evaluation?
Yes
No
Is the Recipient in school and, if so, does he/she have a current IEP, IFSP, 504 Plan?
Yes
No
If yes, what is his/her area of eligibility for special education? (e.g. autism, developmental delay, etc.)
Does the Recipient have a current Behavior Intervention Plan in place via an IEP?
Yes
No
Is the Recipient served in a school Setting?
Yes
No
File Upload (Psychological Eval, Insurance Cards)
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