Intake Form

Comprehensive History Intake Packet
Client and Client's Parent Info
Client/Student Information:
Client Name:

First NameLast Name
Client Date of Birth:

MonthDayYear
Date
Primary home language:
Client's primary language:
Interpreter Required?

YesNo
School Info (if any):
School Grade (if any):
School of Enrollment (if any):
School Address (if any):

Street Address

Street Address Line 2

CityState

Zip Code
School District (if any):
Parent Information (Parent #1)
Name

First NameLast Name
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Relationship to child:
Address

Street Address

Street Address Line 2

CityState

Zip Code
Parent Information (Parent #2)
Name

First NameLast Name
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Relationship to child:
Address

Street Address

Street Address Line 2

CityState

Zip Code

Mankato Full Spectrum ABA

SERVICE AGREEMENT AND CONSENT TO TREATMENT

This Service and Consent Agreement, made on this (Day) day of (Month) , (Year) is between First Name Last Name(responsible party's name) and Mankato Full Spectrum for Applied Behavioral Analysis (ABA) services provided to Client First Name Client Last Name (client's name). Mankato Full Spectrum agrees to provide all services as outlined in the Client Handbook.
I, the client or the client's caregiver, have been given a document with all statements, policies, and procedures related to a therapeutic relationship with Mankato Full Spectrum in the Client Handbook.
These include, but are not limited to:
- Healthcare laws and regulations
- Patient rights regarding PHI
- Client responsibilities
- Complaints process
- Company policies
- Reasons for discharge
I, client or client's caregiver, have reviewed, understand, and agree to these statements, policies, and procedure as outlined by Mankato Full Spectrum.

I, client or client's caregiver, have had general ABA treatment and specific treatment for myself/my child explained to me in a manner in which I can understand (informed consent) by Mankato Full Spectrum. This includes descriptions of myself/my child's skills, deficits, goals, assessment techniques, treatment recommendations, and ABA practices.

I, client or client's caregiver, consent to the services and consent to ABA treatment from Mankato Full Spectrum for
First Name Last Name (client's name). This Service and Consent Agreement shall remain affect for one calendar year from the date above, the client is discharged from Mankato Full Spectrum, or I either party revokes this agreement in writing, whichever happens first.
Responsible Party's Name:*

First NameLast Name
Signature:*

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Date:

MonthDayYear
Date

Mankato Full Spectrum ABA

MUTUAL EXCHANGE OF INFORMATION CONSENT FORM

Client's Name:   First Name*   Last Name*
Client's Date of Birth:   Date*

I,   First Name*   Last Name*   (client's or client's caregiver's name) permit Mankato Full Spectrum ABA LLC to exchange the following types of verbal, electronic, or hard copy information with the other party named above (check all that apply):

Demographic and/or family information
Diagnostic information and/or reports
General health, immunization, and medication records
Treatment plans and/or programming
Treatment goals and/or data Treatment information, anecdotes, etc.
Clinical or session notes
Education records*
I, client or client's caregiver, do not permit Mankato Full Spectrum ABA LLC to exchange the following types of information with the other party named above:
This is consent for the mutual exchange of information will remain valid for one calendar year from the date signed or until the client or client's caregiver revoke their consent in writing, whichever comes first.
Client/Caregiver's Name*

First NameLast Name
Client/Caregiver's Signature*

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Mankato Full Spectrum ABA

FINANCIAL AGREEMENT

This Financial Agreement, made on this (Day)day of (Month)(month), (Year)(year) is between First Name Last Name(responsible party's name) and Mankato Full Spectrum for Applied Behavioral Analysis (ABA) services provided to Client First Name Client Last Name (client's name).
Client Insurance Information
Health Insurance Provider:
Member Name:
Member Date of Birth:

MonthDayYear
Date
Member/ID Number:
Group Number:
Policy Effective Date:

MonthDayYear
Date
Policy Expiration Date:

MonthDayYear
Date
Provider Claim/Benefit Phone Number:
Please enter a valid phone number.
Mankato Full Spectrum agrees to provide ABA services as outlined in the Client Handbook. I, the client's responsible party, agree to provide payment in the forms listed below:
1. Health Insurance Payment: I will provide Mankato Full Spectrum with all necessary information in order to bill my primary and secondary (if applicable) health insurance to cover costs of treatment.
2. Balance Billing: I will allow Mankato Full Spectrum to balance-bill any services not covered by insurance, as allowed by my specific health insurance plan. This may include copays, late fees, deductible payments, or other out-of-pocket expenses. Note: for Medical Assistance clients, balance billing is not allowed, so there are no other out-of-pocket costs for clients.
I, Responsible Party's Name (responsible party's name) agree to these financial statements and enter into this financial agreement with Mankato Full Spectrum. This agreement will remain in effect until the client is discharged from Mankato Full Spectrum or from one year from today's date, whichever is soonest.
Responsible's Party Name:*

First NameLast Name
Responsible's Party Signature:*

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Date:

MonthDayYear
Date
Please attach a copy or a picture of the front of your insurance card. Insurance Card Upload (Front)*

Cancelof
Please attach a copy or a picture of the back of your insurance card. Insurance Card Upload (Back)*

Cancelof

Mankato Full Spectrum ABA

EMERGENCY CONTACT FORM
Child's Information:
Child's Name:

First NameLast Name
Birthday:

MonthDayYear
Date
Home Address:

Street Address

Street Address Line 2

CityState

Zip Code
Parent Information:
Parent or Guardian #1:
Name:

First NameLast Name
Home Phone Number:
Please enter a valid phone number.
Cell Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Home Address:

Street Address

Street Address Line 2

CityState

Zip Code
Place of Employment:
Department:
Parent Information:
Parent or Guardian #2:
Name:

First NameLast Name
Home Phone Number:
Please enter a valid phone number.
Cell Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Home Address:

Street Address

Street Address Line 2

CityState

Zip Code
Place of Employment:
Department:
Emergency Contact Numbers:
Contact #1
Name

First NameLast Name
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Contact #2
Name

First NameLast Name
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Contact #3
Name

First NameLast Name
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Contact #4
Name

First NameLast Name
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Physician's Info:
Physician's Name:
Physician's Address:
Physician's Telephone:
Hospital Name:
Hospital Address:
Hospital Telephone:
Dentist's Info:
Dentist's Name:
Dentist's Address:
Dentist's Telephone:
Parents are responsible for all emergencies charges Child's Health Insurance.
Insurance Plan:
ID#:
Subscriber's Name:
Special Conditions, Disabilities, Allergies, or Medical Emergency Information:
Parent/Guardian Consent and Agreement:
As parent/guardian, I consent to have my child receive first aid by facility staff and, if necessary, be transported to receive emergency care. I will be responsible for all charges not covered by insurances. I consent for the emergency contact person listed above to ACT ON MY BEHALF until I am available. I agree to review and update this information whenever a change occurs or every 6 months.
Parent/Guardian Consent Name:

First NameLast Name
Date

MonthDayYear
Date
Address

Street Address

S

CityState

Zip Code
Signature*

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	Evaluation Preformed:	Date of Evaluation:	By Whom:	Reason/Results
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	Medication:	Dose:	Route:	Frequency:	Start Date:	Reason for Use:	Prescribing Physician:
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9

	Any thoughts?
General health:
Cleanliness
Responsiveness
Friendliness
General health:
Head:
Eyes/Vision:
Ears/Hearing:
Nose/Sinuses:
Mouth/Teeth:
Breathing/Lungs:
GI system/swallowing/digestion/bowels: (i.e., stomachache, constipation, soiling):
Genital and urinary/elimination:
Musculo-skeletal:
Endocrine/hormone:
Neurological: (i.e., concussions, seizures, etc.)
Skin/dermatological: (i.e., rashes, birth marks
Blood/hematological/bruising:
Immune/infections:
Other:

	Organization and Contact Information	Start date of Service	End date of Service
ABA Services (past or present)
Therapist/Counselor
Occupational Therapy (OT)
Speech Therapy (ST)
Physical Therapy (PT)
Family Therapist or Parent Coach
Doctor or Psychiatrist for Medication Management
Children's Mental Health Case Manager
County Case manager
Individual Education Plan (IEP)
Other Service(s)

	Always	Never	Sometimes	Often
Like to point at things
Liked ti show toys to people
Enjoyed being held
Good eye contact, smiling
Played baby games

	Early	On Time	Late	Can't do	Can't recall
Sit without support (Most Children: 6-9 months)
Crawl (Most Children: 9-12 months)
First words (Most Children: 9-12 months)
Walk without holding on (Most Children: 12-15 months)
Use two words together (ex. "Me go") (Most Children: 18-24 months)
Speak in sentences (2-3 years old)
Ride 2 wheeled bike
Potty trained during the day w/o diapers (Most Children: 2-4 years)
Stay dry at night without diapers

	Never	Sometimes	Frequent	Constant
Excessive worry
Panic Attacks
Fear of social situations/interactions
Won't speak
Racing thoughts
Nightmares
Flashbacks
Avoid certain people/places

	Never	Sometimes	Frequent	Constant
Depressed mood
Fatigue/low energy
Feelings of hopelessness
Feelings of abandonment
Feelings of emptiness
Inappropriate guilt
Unable to feel pleasure
Loss interest in past enjoyed activities
Isolation/withdrawal from others
Tearfulness/crying spells
Thoughts of harming self
Self-harming behaviors

	Never	Sometimes	Frequent	Constant
Angry Outbursts
Refusing to do what is asked
Aggressive towards peers
Aggressive towards family
Aggressive towards teachers/peers
Cursing and swearing
Won't listen to authority
Stealing
Lying
Excessive energy
Uncharacteristic and/or risky behavior
Easily distracted
Inattention
Hoarding
Self-stimulation
Self-Injury

	Never	Sometimes	Frequent	Constant
Bedwetting
Soiling
Picks skin, bites nails
Tics or odd movements
Sleep problems
Eating problems
Seems out of touch with reality
Does things over and over again

	Never	Sometimes	Frequently	Constant
Refusing to go to school
Refusing to do schoolwork
Won't follow rules
Gets suspended
Loses things frequently
Difficulty focusing
Works below ability
Can't keep up with schoolwork

	Well	Somewhat Average	Poorly
Brothers, Sisters
Other kids the same age
Older kids
Younger kids
Teachers
Other adults

	Diagnosis:	Date of Diagnosis:	By Whom:
1
2
3
4
5
6
7
8
9

	Full Name:	Relationship to Client:	Age:
1
2
3
4
5
6
7
8

	Full Name:	Relationship to Client:	Age:	Living Where:
1
2
3
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5
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Comprehensive History Intake Packet