TLC Pre-Intake Form 2023

MEDICAL DOCUMENTATION
Does your child have a medical autism diagnosis?*

NoYes
Please upload a copy of your child's autism diagnosis below:*

Cancelof
If your child does not have a medical autism diagnosis, we are unable to proceed with our intake. In order for your insurance to approve ABA therapy, a medical diagnosis is required. Please contact our office to get a list of diagnosing providers. We also recommend for you cntact your insurance and get a list of in-network diagnosing providers.

Please submit this form so we can keep your contact information and follow-up with you.

SCHOOL & IEP DOCUMENTATION
Is your child currently enrolled in school?*

NoYes
Name of School*
Teacher's Name*
Name of Aide*
What placement is your child in? (check all that apply)*

General EducationSelf-Contained
Percentage in General Education*
Percentage in Self Contained*
Most current IEP* Date*

MonthDayYear
Date
Annual IEP Date*

MonthDayYear
Date
Does your child have any history of disciplinary action? (e.g., suspension, detention)*

NoYes
If yes, please provide detail below:*
Please upload a copy of your child's most recent IEP

Cancelof

Scheduling and Availability
The Lovaas Center ABA Plans & Availability

Our organization offers two types of plans: Comprehensive and Focused. We currently offer in home therapy, in center therapy, or a hybrid model of both in home and in center therapy.

Comprehensive plan consists of:
- 25 to 40 hours a week of one-on-one therapy with an RBT
- 20 to 32 hours of monthly supervision of the RBT
- 4 to 6 hours of monthly parent training
Focused plan consists of:
- 15 to 24 hours a week of one-on-one therapy with an RBT
- 10 to 20 hours of monthly supervision of the RBT
- 4 to 6 hours of monthly parent training up to 1 year plan only
Hours are based on your Behavioral Analyst recommendation and your child's needs. Please ensure you provide the most accurate availability for ABA services as our Scheduling Coordinator will prioritize the days and times requested on this form.

*** We currently do not accept plans below 15 hours a week of one-on-one therapy***
I'm interested in:*

In-Home OnlyIn-Center OnlyHybrid Model - Home and Center
For center-only and hybrid models, the following scheduled are available:

Children ages 18 months to 5.9:
- 8:00 AM to 3:00 PM (Center Availability)
  - Currently unavailable
Children ages 6 to 9:
- 1:00 PM to 7:00 PM (Center Availability)
  - After-school availability may be limited
For home-only, the following schedule is available:
- Sunday to Saturday
  - Morning availability
***After-school in-home is currently unavailable***

I understand that the availability provided above is the most accurate for ABA services. I understand that any availability changes from the date of this form submission to the date of your full treatment authorization may result in discontinuing the intake process or delay the start of treatment.
Parent/Legal Guardian Name*
Parent/Legal Guardian Signature*

Clear
Please tell us how you heard about The Lovaas Center:
Thank you for choosing us for your child's needs. Our Intake Coordinator will be contacting you within 24-48 business hours of receiving your request.
Should be Empty:

The Lovaas Center for Behavior Intervention Pre-Intake Form