Intake Form

Client Name *

Client DOB *

Client Gender *

Parent/Guardian Name *

First and last name

Parent/Guardian phone number *

Parent/Guardian email address *

Address line 1 *

Address line 2

City *

State *

Zip Code *

Availability for in-home ABA sessions *

Please include days of the week and specific times e.g. MWF 3-6 pm, TTh 2-5 pm, weekend availability

Referral source *

Funding source *

Brief description of client needs *

Are you currently receiving ABA services? If so, through what agency?

Does your child currently have an autism diagnosis? *

Does the child have a safety risk?

Please describe safety risk, if any:

Please upload a Diagnostic Assessment

Click or drag a file to this area to upload.

Primary Insurance Card or Military ID (front)

Click or drag a file to this area to upload.

Primary Insurance Care or Military ID (back)

Click or drag a file to this area to upload.

Secondary Insurance Card (front and back)

Click or drag a file to this area to upload.