• Image field 55

  • ABA Screening and Intake Form

  • Are you 18 years or older and legally able to make your own decisions, or are you a parent/legal guardian completing this form for a minor or someone under guardianship?*
  • Before we can schedule your appointment, you'll need to complete our intake paperwork. Once you finish this screening form, we'll send the documents to you. How would you prefer to receive your intake forms?*
  • Primary Language*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you have legal paperwork that establishes custody or guardianship of the child?(If so, you will be asked to upload it.)*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Patient Date of Birth*
     - -
  • Which area of NC would you like to receive services in (please note we only currently have a clinic in the Fayetteville Location - all other listed areas will be in home/daycare/school)?*
  • Do you have a Secondary Insurance? Please note that you are required to inform us of all insurance coverage and if you do not have secondary insurance coverage, you must indicate that.*

  • History

  • Has your child received a diagnosis of Autism Spectrum Disorder? This is a formal diagnosis given by a physician or behavioral pediatrician that should include a severity level of 1, 2 or 3.*
  • Has your child received previous ABA services?*

  • Insurance Companies require a diagnosis of Autism Spectrum Disorder to authorize ABA Services.

    Until your child has this formal diagnosis, we are unable to move forward with getting them set up with us for ABA services.
  • Below are some local agencies that offer psychological testing to determine a diagnosis. You are welcome to seek testing at a facility of your choice.
  • We are really looking forward to giving your child the treatment that they need. We are unable to move forward in any way until we have a diagnosis if you are using insurance for payment If you have general questions about treatment please email us at admin@fayettevillenewleaf.com.*

  • Current Schedule/Services

    When inputting schedule availability, please keep in mind that final schedules will be decided after the assessment to best determine the needs of your child. All schedules should be for a minimum of 6 months in duration. 
  • Is your child enrolled in school/daycare/homeschool? (Check all that apply)*
  • Days child is enrolled in school. (Check all that apply)*
  • Days child is enrolled in daycare. (Check all that apply)*
  • Does your child have an IEP or IFSP?*

  • Please note: The time and location of services selected must be consistent. Please ensure your child has appropriate travel accommodations set in place to attend scheduled sessions. 

  • Preferred Location of Services (Check all that apply)*
  • Rows

  • Presenting Problems and Treatment Barriers. Please be as descriptive as possible.

  • Child's method of communication (Please check all that apply)*
  • Presenting Problem Behaviors (Check all that apply)*

  • *Your submission below indicates that the information you have provided above is truthful. Once this form is submitted, you will be redirected to our intake packet. Please note, all intake forms must be completed to move forward with potential services. 

  • Should be Empty: