Kids N Heart - Intake Form
Patient Information
Patient's Name
*
First Name
Last Name
Patient's Birth Date
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Year
Gender (as listed with insurance)
*
Female
Male
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Family Information
Parent 1/Legal Guardian/Authorized Representative’s Name
*
Relationship to Client
*
Address (if different than Client)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary email address
*
example@example.com
Parent 2/Legal Guardian/Authorized Representative’s Name
Relationship to Client
Address (if different than Client)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary email address
example@example.com
Marital Status
*
Single
Married
Divorced
Separated
Remarried
Widowed
Cohabitants
Other
If divorced, who has Physical Custody:
Parent 1
Yes
No
If yes, full or joint Legal Custody?
Full
Joint Legal Custody
Parent 2
Yes
No
If yes, full or joint Legal Custody?
Full
Joint Legal Custody
If Parent 1 Remarried: Name of Stepparent
If Parent 2 Remarried: Name of Stepparent
If Parent 1 Cohabitating: Name of Partner:
If Parent 2 Cohabitating: Name of Partner:
Emergency Contact #1 Name:
Relationship:
Address:
Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #2 Name:
Relationship:
Address:
Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Home Information
If parents are divorced:
What is the co-parenting schedule?
What is the visitation schedule of any siblings or step-siblings (as applicable)?
If Extended family or others living in the home:
Name:
Age:
Relationship:
# years in home:
Name:
Age:
Relationship:
# years in home:
Any legal involvement?
Yes
No
If yes, please explain:
PRIMARY LANGUAGE SPOKEN AT HOME?
OTHER LANGUAGES YOUR CHILD IS EXPOSED TO?
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Intake Form
Patient Information
What location do your prefer for ABA services (choose all that apply)?
*
Home
Daycare
Other
Days/Hours Available for ABA Services
*
Daycare/School Information (If Applicable)
Daycare Name
Daycare Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Intake Form
Insurance Information
Primary Insurance Provider
*
Subscriber ID
*
Group #
Name of Insured/Policy Holder
*
First Name
Last Name
Policy Holder Date of Birth
*
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January
February
March
April
May
June
July
August
September
October
November
December
Month
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1
2
3
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5
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7
8
9
10
11
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19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
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2025
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2021
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2015
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2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Relationship to Patient
*
Secondary Insurance Provider
Subscriber ID
Group #
Name of Insured/Policy Holder
First Name
Last Name
Policy Holder Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
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2025
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2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Relationship to Patient
Insurance Card (Front)
*
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Insurance Card (Back)
*
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Please attach a copy of your Autism diagnosis.
*
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Please attach a copy of your IEP (if you have one)
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Consent to Release Documents and Contact Insurance or Doctor's Office
By signing below, I grant Kids N Heart permission to contact my insurance, healthcare provider, and school personnel on my behalf to obtain any necessary documents, forms or approvals.
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