HALC ABA Clinic Services In-Take Form

Client Name

First NameLast Name

Date of Birth

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

May I text the number provided regarding information about appointments or needed documents?

Parent Name

Parent's Email Address

School

Grade

Case Manager

Case manager's email

What environment are you requesting services for?

Educational Environment (Check all that apply)

Medical Diagnosis (List all)

Medication and Doses

Does your child currentlyreceive Clinical Services fromany outside facility? (In-Clinic ABA,Speech and/or OT)

Does your child currently receive services for mental health under the care of a psychiatrist or mental health counselor?

REQUIRED: Consent to Provide Therapeutic Services I am providing consent to receive Applied Behavior Analysis Services. I give consent for Howard’s Autism Learning Center, LLC, which will provide ABA services. I understand that I may request clarification, ask questions, and/or terminate services at any time. Please sign

REQUIRED: CONSENT FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR TREATMENT AND HEALTHCARE OPERATIONS: By signing below, you hereby consent to use or disclose information about yourself and/or your child (or another person for whom you have the authority to sign) that is protected under federal law for the sole purpose of treatment and health care operations. Please sign

REQUIRED: CONSENT FOR USE OR DISCLOSURE OF PROTECTED HEALTHINFORMATION FOR TREATMENT, AND HEALTH CARE OPERATIONS: By signing below, you hereby consent for Howard’s Autism Learning Center, LCC to use or disclose information about yourself and/or your child (or another person for whom you have the authority to sign) that is protected under federal law, for the sole purpose of treatment and health care operations.

Client's Form of Communication

What are items, activities, and food your child enjoys?

What behaviors are you concerned about? (example: hitting, crying, screaming) Please try to describe what the behavior looks like

What happens before behaviors of concern? List behaviors in order of concern and check boxes for what happened before. Ex: you take away an item, they are told to do something they do not like to do, Not being given attention

How do people in the environment respond to the behaviors? List behaviors and check boxes for what happens after your child engages in behavior. Ex: Provided the item, provided attention, like comforting/reprimand, ignored, Told they do not have to follow instructions

What do you think your child is trying to communicate with their behaviors?

What are your goals for your child in the school environment? Example: Gain Independence, Increase Social skills,Decrease problem behavior,Increase academic skills, increase communication skills,Increase functional skills

Please provide any additional information you would like us to know about your child.

I provide consent for Howard's Autism Learning Center to conduct a Functional Behavior Assessment (FBA) and develop a Behavior Intervention Plan(BIP) if the data from the FBA warrants one and understand that ALL documents will be reviewed with me prior to implementation of the BIP.

Diagnosis Documentation (Clinic Services Only)

Individualized Education Plan (IEP) (Clinic Services Only)

Picture of Insurance Card (Clinic Services only)

Parent Handbook Signature pages (email alicia@howardsautismcenter.com for a copy)