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.Format: (000) 000-0000.
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? Please be specific: company name, doctor name, other therapist name and/or company
(Referral, Google, Job Posting, etc.)
Are you the primary Guardian for the child?
Guardian Name

First NameLast Name
Guardian Phone
Please enter a valid phone number.Format: (000) 000-0000.
Guardian Email
example@example.com
Preferred Language
Child's Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex
Who lives in the household? (Ex: mom, dad, older brother, grandma, etc.)
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

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Do you have a case manager?
Case Manager's name (if known)
Name of your Pediatrician or Primary Healthcare Provider
enter provider or clinic name
Has your child received a diagnosis from a pediatrician or other medical provider? Or have they had an assessment or evaluation completed?
List Diagnoses they received:
If you have a copy of the assessment or diagnosis paperwork, please attach it below

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Enrollment Information
How soon do you want to start services?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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?
Is your child currently enrolled in school?
Has your child qualified for an IEP or 504 plan?
Academics: Is your child academically...
What type of ABA services has your child received?

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

Rows	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?
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 upload your child's immunization records:

If you do not have these records available, please reach out to your doctor and submit at a later time.
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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?
Signature
Should be Empty:

Client Enrollment Form

Child's Information

Enrollment Information

Caregiver Cooperation