HALC ABA Services In-Take Form
Client/ Student Name
First Name
Last Name
Date of Birth
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Parent Name
Parent's Email Address
School
Grade
Case Manager
Case manager's email
What environment are you requesting services for?
School (IEP team decision)
Oneonta Clinic Location (Insurance, school-funded, or private pay)
Cullman Clinic Location (Insurance, school-funded, or private pay)
Educational Environment (Check all that apply)
General Education Setting
General Education/Resource Services
Self-Contained/ Small group
Full Days
Half Day
Homeschooled/ Homebound
Medical Diagnosis (List all)
Medication and Doses
Does your child currentlyreceive Clinical Services fromany outside facility? (In-Clinic ABA,Speech and/or OT)
ABA at School
OT
Speech
ABA at another organization
Does your child currently receive services for mental health under the care of a psychiatrist or mental health counselor?
Yes
No
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
Pointing and Indicating
One word phrases
Sentences
AAC Device
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)
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Individualized Education Plan (IEP) (Clinic Services Only)
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Picture of Insurance Card (Clinic Services only)
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Parent Handbook Signature pages (email alicia@howardsautismcenter.com for a copy)
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Continue
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