2025 Client Intake Form

Client Enrollment Form

Thank you for your interest in the BehaviorSpan intensive ABA program. The following questions will help determine the best placement for your child within our program.
Your Name*

First NameLast Name
Relationship to child*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Ex: Jefferson County, Denver County, Arapahoe County, etc.
How did you hear about us?
(Referral, Google, Job Posting, etc.)
Are you the primary Guardian for the child?*

YesNo
Guardian Name

First NameLast Name
Guardian Phone
Please enter a valid phone number.
Guardian Email
example@example.com
Preferred Language
Child's Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex*
Household Occupants*
List of current household occupants (mom, dad, siblings, grandparents, etc.)
Primary Insurance*
If you have a copy/image of your child's insurance card, please attach it below

Cancelof
Do you have a case manager?*

YesNo
Case Manager's name (if known)
Has your child received a diagnosis from a pediatrician or other medical provider?*

YesNo
List Diagnoses they received:
If you have a copy of the diagnosis paperwork, please attach it below

Cancelof
Enrollment Information
How soon do you want to start services?

MonthDayYear
Date
Please describe the services you are looking for:
What are your goals for your child in the next 5 years?
How would you rate your child's communication skills?*

1

2

3

4

5

1 is They don't use any words correctly, 5 is They are able to ask for things and label items
Does your child engage in any of the following?*

AggressionDangerous Self-InjuryProperty DestructionNone of the Above
Is your child currently enrolled in school?*

YesNo
Has your child qualified for an IEP or 504 plan?

YesNo
Academics: Is your child academically...

On par with peersBelow par with peersSeverely below par with their peers
What type of ABA services has your child received?*

Center-basedIn-homeNo prior ABA services

Have you received any of the services below in the last 2 months? (Select all that are applicable)

	Check if you've received	How many sessions per week (Number)	Name of Company thoughts?
Speech-Language Pathologist (SLP)
Occupational Therapy (OT)
Physical Therapy (PT)
Applied Behavior Analysis (ABA)

We partner with SLPs and OTs and they provide services at our centers. Would you like us to assist in setting this up?*

Yes, I would like a new providerNo, I have a current provider that can provide services at the center
When did you realize that your child was missing their milestones?*
How did you react? What help did you seek?
Medical Conditions*
Please list medical conditions that your child may have (ex: asthma) as well as other diagnoses apart from Autism Spectrum Disorder.
Current Medications*
List the medications your child takes, if any
Please select the vaccines your child has received:*

Hepatitis B (HepB)Diphtheria, tetanus, pertussis (DTaP)Inactivated poliovirus (IPV)Measles, mumps, rubella (MMR)Varicella (chickenpox)Tetanus, diphtheria, pertussis (Tdap)None
Dietary restrictions or allergies:*
Is your child allergic to specific foods or environments?
Caregiver Cooperation

Caregiver cooperation is critical to achieving high quality, effective, and meaningful treatment results. This requires our caregivers to maintain consistent attendance, engage in parent training, cooperate with the child's team, and overall, consistently engage in the child’s uniquely tailored programs. For the following page, we ask that you keep these standards in mind and note any limitations that may affect them.
We will need you to commit to the following:

- Maintaining consistent attendance, and making your child's treatment a top priority

- Participating in at least 1 hour of parent training per month

- If deemed appropriate from their assessment, entering your child in full-time services (up to 40 hours/week)
Are you able to commit to the above?*

YesNo
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