Spring/Summer ABA Group Intake Form

Spring/Summer ABA Group Intake Form

Core Clinical Autism Services - 2-hour time blocks (9 am - 11 am/11:30 am - 1:30 pm/ 2pm - 4pm)
I am a... [Client requesting services/Parent or caregiver/ Medical Professional or Community Agency]
Date of Birth of the individual being referred

MonthDayYear
Date
What time of Spring/Summer ABA Group are you requesting? What is the 2-hour time block desired and the number of weeks.
Parent or Caregiver Information / Medical Professional Information/Community Agency and Contact Information
Name

First NameLast Name
Main Phone
Format: (000) 000-0000.
Phone Number
Format: (000) 000-0000.
Email
example@example.com
- I have consent from the individual or their legal guardian to request services
- Relationship to the client
- Email
- Preferred Method of Contact
- Organization
- Job Title
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Support/Accommodation Needs
- Client Name
  
  First NameLast Name
- Preferred Name
- Date of Birth
  
  MonthDayYear
  Date
- Gender
- I identify as...
- Main Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Mobile
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Pronouns
- Race, ethnic or cultural background (select all that apply):
- Other (Specify):
- Preferred Method of Contact
- Employment
- Address
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Health Card Number
  
  Version
- Family Doctor [Name/Location]
- What is the name of the school the student is currently attending? (if applicable)
- Referral Name
  
  First NameLast Name
- Provincial Funding Information
- Ontario Autism Program(OAP) Number [If known/applicable] - Direct Funding or Fee-for-Service Funding option?
  This number is issued after registering with the Ontario Autism Program.
- Ontario Disability Support Program Member ID (If Applicable)
  This is a 9-digit number issued to ODSP members.
- Insurance Information
- Name of Insurer
  
  First NameLast Name
- Insurer Phone Number
  Format: (000) 000-0000.
- Policy Number
- Group Number
- Client Support Needs
- Confirmed or suspected diagnoses
- Do you have any physical health conditions or chronic illnesses?
- List any physical, visual, hearing, or other supports required
- How would you describe the client's strengths and interests?
- Please let us know about any behaviour/communication/safety concerns or sensory needs.
- Are there any allergies, medications or other concerns we should know about?
- Has the client participated in any Ontario Autism Program (OAP) before (e.g., Speech and Language Pathologist-SLP/ Occupational Therapist-OT etc.)?
- If yes please specify:
- What are some goals that you have for the client?
- Mental Health and Wellness Services
- Reason for Seeking Care (Check all that apply)
- Please describe in your own words the issue(s) you would like help with:
- Mental Health History
- Have you previously sought therapy or counselling?
- If yes, please provide details (e.g., type of therapy, how long ago, results):
- Do you have any previous diagnoses (e.g., depression, anxiety, PTSD, etc.)?
- If yes, please provide details (dates, reasons, treatment):
- Have you ever been hospitalized for mental health issues?
- If yes, please provide details (dates, reasons, treatment):
- Do you have a history of mental health issues in your family?
- If yes, please specify:
- Do you have a good support network (friends, family, etc.)?
- Are you currently taking prescription medication?
- Please Specify:
- Prescribing Doctor's Name
  
  First NameLast Name
- Prescribing Doctor's Phone
  Format: (000) 000-0000.
- Reason for seeking help
- Goals for Therapy?
- Current Symptoms
- Please check any symptoms you have been experiencing recently:
- Other symptoms:
- If you require emergency services and have an urgent concern about your well-being or the safety of others, please visit your local hospital or dial 9-1-1, text/call 9-9-8 for the 24/7 Mental Health and Suicide Prevention Hotline, contact the Kids Help Phone at 1-800-668-6868, or Community Crisis Response Service at 1-855-310-COPE (2673) serving Durham and York regions.
- OTHER INFORMATION
- Please let us know other information you would like to share that may be useful to the intake process.
- Subscribe
- Subscriber Name
  
  First NameLast Name
- Subscriber Date of Birth
  
  MonthDayYear
  Date
- Subscriber Relationship to Patient
- I want to hear about Equanimity Behaviour Analyst Inc., new services, resources, and events. You can unsubscribe at any time.
  
  Other
- *Your signature below indicates that the information you have provided above is truthful and demonstrates a committment to accessing services with Equanimity Behaviour Analyst Inc.
  
  *Pre-requisite Skills (varies across groups): Shows interest in peers; Can join group activities for up to 20 minutes; Enjoy sharing their interest; These programs may not be suitable if your child; Does not yet speak in full sentencesShows little interest in socializing; Displays behaviours that could cause injury or require emergency help.
  
  *Your signature below indicates that you confirm that your child meets the criteria to participate in Equanimity Behaviour Analyst Inc.'s Spring/Summer programming.
- Date
  
  MonthDayYear
  Date
- Signature
- Should be Empty:

Parent or Caregiver Information / Medical Professional Information/Community Agency and Contact Information

Provincial Funding Information

Insurance Information

Client Support Needs

Mental Health and Wellness Services

Mental Health History

Current Symptoms

OTHER INFORMATION

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