ALABAMA - BeeKind ABA Therapy Website Enrollment Form 2026

Child/Adolescent History and Intake Form
The purpose of this document is to provide background information regarding your child. This form has been designed to ask questions about you and your child’s history and behavioral concerns. If your child has an active IEP, is currently taking ANY medications, has an Autism diagnosis with a psychological report, please send in these documents after completing this
form.
Child's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Autism Spectrum Diagnosis (ASD)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of the diagnosing physician/psychologist.
Have you ever received behavioral health services (ABA) in the past? No or Yes? If yes, what was the approximate ranges of dates you saw that provider for? Who was the provider? What were your child's responses to the treatment provided (e.g., what worked, and what didn't work?
Name of the practice and location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your child currently receiving behavioral health services from another provider? No or Yes. If yes please list the provider.
Is your child currently experiencing homicidal or suicidal ideations? If yes, describe below.
Communication Skills: How does your child communicate his or her needs? words, gestures or other form of communication used.

Attention-deficit/hyperactivity disorder (ADHD)
Attention-deficit/hyperactivity disorder (ADHD) is marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. People with ADHD experience an ongoing pattern of the following types of symptoms:

Inattention means a person may have difficulty staying on task, sustaining focus, and staying organized, and these problems are not due to defiance or lack of comprehension.

Hyperactivity means a person may seem to move about constantly, including in situations when it is not appropriate, or excessively fidgets, taps, or talks. In adults, hyperactivity may mean extreme restlessness or talking too much.

Impulsivity means a person may act without thinking or have difficulty with self-control. Impulsivity could also include a desire for immediate rewards or the inability to delay gratification. An impulsive person may interrupt others or make important decisions without considering long-term consequences.

Many people experience some inattention, unfocused motor activity, and impulsivity.
Has your child been officially diganosed with ADHD?
If your child has ADHD, has your child been prescribed any medications for ADHD?
If your child has been officially diagnosed with ADHD, are you going to implement medication?

Responsible Parent(s)/Caregiver
Legal Guardian 1

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred Method of Contact:
Legal Guardian - 2

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Are the individuals listed above the birth parents? If not, please describe the frequency of contact with the birth parents and their involvement with the client.
Pertinent Family History: Please describe any relevant medical family history (e.g., sibling/caregiver's psychological diagnosis, medical conditions, medications/treatments, substance abuse, etc.) that could affect your child's behavior, treatment implementation, and/or the participation of team members.
Describe any legal or marital issues that may impact the implementation of services (e.g., divorce, guardianship, custody issues, etc.)
Previous Interventions?
Is your child involved in any extracurricular activities?

Home & Parent Information
Please list other individuals that live in the home with the child.
Language Spoken at Home:
What area of the home would you like hold sessions?
Department of Child and Family Services (DFCS) involvement if any? If so, provide caseworker contact information. If no involvement, please put "Not Applicable."
Observation of Religious Holidays:
Do you have any pets? If so, what type?
Do you have any broken locks or windows that pose a concern?
Have there been previous attempt to escape the home?
Does your child engage in elopement?
Does your child engage in dangerous behaviors? (suicidal, fire setting,etc?
Is there a pest infestation in the home? (bed bugs, roaches, etc.)
Is there a Domestic Violence/Restraining order in place?

Proposed Scheduling
Proposed schedule for ABA services. (not permanent)
Parent Employment. (Current employer, full/part time, date and address).
Parent Employment. (Current employer full/part time, date and address).

Authorization to Release Medical Records & Information Consent Form
Please provide contact information for any clinicians, insurance contacts, therapy providers, school personnel or other individuals your ABA consultant may share your child’s therapy progress with. Maintaining communication with physicians and other care providers can help create consistency of care for your child.

BeeKind ABA Therapy personnel are required to maintain confidentiality regarding your child’s identity. Client files will be faxed to reduce risks associated with electronic communication.

Participation in consent is voluntary. You may revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon the authorization. The authorization will expire six (6) months from the date of my signature, unless you revoke the authorization prior to that time. If there are any questions concerning consent to communication or confidentiality, please contact your assigned Board Certified Behavior Analyst.
Client Name:

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Authorized Contacts:
Please check all of the provider types your child comes in contact with. (This may be required by your insurance for approval.) *

Other
Please enter the contact information for each authorized contact.
YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ AND COMPLETED BEEKIND ABA THERAPY LLC AUTHORIZATION TO RELEASE MEDICAL RECORDS/INFORMATION AND THAT YOU AGREE THAT YOUR CHILD’S THERAPY PROGRESS SHOULD BE SHARED WITH THE CONTACTS LISTED ON THIS FORM. THIS INCLUDES SHARING THE BEHAVIORAL ASSESSMENT AND REPORT WITH YOUR CHILD'S INSURANCE PROVIDER.
You understand that after submitting this form that you will recieve an emailed consent of ABA services & BeeKind ABA Therapy policies and procedures. You MUST sign the emailed consent form to complete enrollment.
Parent/Legal Guardian Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Cargiver Signature

Document Upload
Attention!

In addition to completing this form, you will need to include the documents below by uploading.
Please upload the requested documents below. Failure to send in the requested documents can result in a delay of services.

 Psychological Evaluation with Autism Diagnosis (REQUIRED)
 Letter of Medical Necessity (REQUIRED)
 Copy of Insurance Cards (front and back) (REQUIRED)
 Copies of any school support programs (Individualized Education Plan (IEP),
504 Plan, etc). - (IF APPLICABLE)
File Upload

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Should be Empty:

Alabama BeeKind ABA Therapy Online Enrollment 2026-27 & Client Insurance Eligibility Form

Primary Insurance

Secondary Insurance

Child/Adolescent History and Intake Form

Attention-deficit/hyperactivity disorder (ADHD)

Additional Diagnoses

Private/Public School Information

Responsible Parent(s)/Caregiver

Child Background

Client Medical History

Home & Parent Information

Proposed Scheduling

GA Medicaid Mandatory Coversheet for PA

Authorization to Release Medical Records & Information Consent Form

Authorized Contacts:

Document Upload