ABA Screening and Intake Form

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?*

Yes, I am 18 or older and can legally make my own decisions.No, I am completing this form as a parent/legal guardian 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?*

Text Message (SMS)Email
Primary Language*

EnglishSpanishOther

Parent/Legal Guardian Name*

First NameLast Name
Parent/Legal Guardian Primary Phone*
Parent/Legal Guardian Secondary Phone
Parent/Legal Guardian Email*
example@example.com
Do you have legal paperwork that establishes custody or guardianship of the child?(If so, you will be asked to upload it.)*

No — I am the legal caregiver, and no custody paperwork exists.Yes — I have legal custody/guardianship and will upload documentation

If applicable, please upload the legal paperwork establishing custody or guardianship (e.g., custody order, DSS paperwork, guardianship documents). *

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Patient Name*

First NameLast Name
Primary Phone*
Secondary Phone
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Date of Birth*

MonthDayYear
Date
Patient Marital Status*
Primary Care Provider*
Phone
ADA Accommodations
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)?*

Cumberland CountyRobeson CountyBrunswick County (Leland)New Hanover CountyHoke CountyOther

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.*

YesNo

Upload the front of the secondary insurance card covering the client.*

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Upload the back of the primary insurance card covering the client.*

Cancelof

If Tricare is one of the insurances listed, please provide Sponsor's Full Name. (Please put "N/A" if not applicable)*
If Tricare, please provide Sponsor's SSN. (Please put "N/A" if not applicable)*
If your child has Tricare, is the Sponsor active duty or retired?*

Active DutyRetiredNot Tricare
If your child has Tricare, was insurance active when your child was born?*

YesNoNot Tricare

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.*

YesNo
Has your child received previous ABA services?*

YesNo

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.

The Haymount Institute: ph: (910) 860-7008Fayetteville Neuropsychology: ph: (910) 677-0000Anchor Psychology ph: (910) 270-9995 *located in Hampstead, but it was reported to us that they have short wait time.
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.*

I understand and wish to continue and be placed on a waitlist until my child has a diagnosis of Autism Spectrum DisorderI am paying privately and am not using insurance to fund treatment.I understand and will be moving forward as my child already has a diagnosis of Autism Spectrum Disorder.

*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.
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History