All About Me Packet

All About Me (Client Intake)

Welcome! Please complete this comprehensive intake form to help us understand your child's needs and coordinate care effectively.
Today’s Date*

MonthDayYear
Date
Child's Legal Name*
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleNon-binaryPrefer not to say
Primary Language*
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Availability for Session(s)*

Morning (8:00 a.m. – 12:00 p.m.)Afternoon (12:00 p.m. – 4:00 p.m.)Evening (4:00 p.m. – 7:00 p.m.)
Preferred Session Setting(s)*

HomeSchoolDaycareCommunity
Family Information

At Honey BeeHavior Kids, we know that every hive is unique—and understanding your family helps us provide meaningful, personalized care for your child. Please complete the section below so our team can best support your family’s needs and communication preferences.
The child lives with (list family members)
Parent/Guardian Name*

First NameLast Name
Relationship to Child*
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Employer
Occupation
Employer Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Employer Phone
Please enter a valid phone number.
Secondary Parent/Guardian Name

First NameLast Name
Relationship to Child (Secondary)
Phone Number (Secondary)
Please enter a valid phone number.
Email Address (Secondary)
example@example.com
Employer (Secondary)
Occupation (Secondary)
Employer Address (Secondary)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Employer Phone (Secondary)
Please enter a valid phone number.
Emergency Contacts – Name, Relationship, Phone*
Insurance Information

I understand that all records and information regarding myself and/or my child are protected by law. Information about my child’s treatment will not be released without my written consent, except as permitted or required by law. I understand that I may revoke this consent at any time in writing.I hereby give authorization for Honey BeeHavior Kids to contact and share necessary medical and treatment information with my primary and secondary (if applicable) insurance providers for the purpose of processing claims and securing payment for services rendered.I authorize my insurance company to pay benefits directly to Honey BeeHavior Kids for services provided to myself and/or my dependents. I understand that my signature on this document serves as authorization for all future claims submitted on my behalf or on behalf of my dependents, without requiring my signature on each individual claim.I acknowledge that I am financially responsible for all charges incurred, including any amounts not covered by insurance (such as deductibles, co-pays, co-insurance, or non-covered services). I further understand that any insurance benefits received by Honey BeeHavior Kids will be applied to my account in accordance with this authorization.
Primary Insurance Name*
Member/MA Number*
Group Number*
Subscriber Name*
Subscriber DOB*

MonthDayYear
Date
Subscriber Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Subscriber Phone Number*
Please enter a valid phone number.
Secondary Insurance Name (Optional)
Secondary Insurance Member/MA Number (Optional)
Insurance Cards (Front and Back)*

Cancelof
Medical Information

At Honey BeeHavior Kids, your child’s health and safety are our top priorities. To ensure we provide the best care possible, please complete the following section with accurate and up-to-date medical information.This information helps our clinical team understand your child’s overall wellbeing and collaborate effectively with medical providers when needed. (All information shared is confidential and protected under HIPAA.)
Permission to Contact Doctor*

YesNo
Primary Doctor (Name)*
Doctor’s Phone Number*
Please enter a valid phone number.
Allergies (Please List)
Medical Restrictions (If applicable)
Current Medications (Please list name and dosage)
Additional Service Providers

At Honey BeeHavior Kids, we believe that children thrive when everyone involved in their care works together—just like bees in a hive, each playing an important role in growth and success. To support consistent communication and collaboration, please list any other professionals or service providers currently working with your child. This helps our team coordinate care, share progress (with your consent), and ensure your child’s treatment plan supports all areas of development.
School Name
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Teacher’s Name
Grade
Speech Therapy Provider (Name and Phone)
Occupational Therapy Provider (Name and Phone)
Physical Therapy Provider (Name and Phone)
Additional Providers (Name and Contact Information)
Neuropsychological or Diagnostic Evaluation
Upload Neuropsychological or Diagnostic Evaluation (PDF or Image)*

Cancelof
Date of Evaluation

MonthDayYear
Date
Diagnosing Provider/Facility
What are your main concerns or goals for your child’s growth and development?*
What are your child’s greatest strengths, interests, or qualities that make them shine?*
Consent & Signature

I confirm that the information I’ve provided is accurate and complete to the best of my knowledge.

I give my consent for Honey BeeHavior Kids to:
- Provide Applied Behavior Analysis (ABA) therapy to my child as part of their individualized treatment plan.
- Submit clinical documentation and identifying information (such as name, date of birth, and diagnosis) to my insurance provider for the purpose of obtaining prior authorization for ABA services.
- Communicate with my insurance provider regarding treatment plans, service authorizations, and medical necessity, as required to coordinate care and process claims.
I understand that I may withdraw this consent at any time by providing written notice.
Parent/Guardian Signature*

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Printed Name*
Relationship to Client
Date of Signature*

MonthDayYear
Date
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All About Me (Client Intake)