Intake Paperwork & Form

Please fill out this packet. This information assists in the evaluation process.

PERSONAL INFORMATION

Person Completing Intake Packet

Relation to Patient

PATIENT INFORMATION

Child’s First Name

Child’s Last Name

Date of Birth

Nickname/Preferred Name

Parent Email:

Address

Country/Region

Address

City

Zip / Postal code

Home Phone

Alternate Phone

School

Grade

RESPONSIBLE PARTY INFORMATION

Guarantor’s Name

Date of Birth

Social Security Number

Relation to Patient

Different Address than Patient?

Yes

Home Phone

Alternate Phone

Employer

EMERGENCY CONTACT INFORMATION

Name

Alternate Phone

Home Phone

Relation

INSURANCE INFORMATION

Primary Insurance Name

Policy ID #

Group #

Subscriber’s Name

DOB

Relation to Patient

Secondary Insurance Name

Policy ID #

Group #

Subscriber’s Name

DOB

Relation to Patient

Child is Our

Biological

Adopted

Foster Child

Siblings

Name, Age, M/F, Speech, and Hearing or Other Medical Conditions

MEDICAL HISTORY

Primary Care Physician

Date of Last Visit

Multi-line address

Country/Region

Address

City

Zip / Postal code

Office Phone

Medical Issues

Allergies

Current Medications

SCHOOL HISTORY

Preschool

Age Level/Teacher

Elementary School

ASSOCIATED SERVICES

Physical Therapy

Speech/Language

Occupational Therapy

Psychological Testing

Current Medications

CONCERNS

Difficulty with Change

Food Selectivity

Sleep Disruption

Functional Communication

Stereotypy (Verbal)

Stereotypy (Motor)

Hygiene

Toileting

Aggression

Self-Injurious Behavior

Elopement

Impulsive Behavior

Any other Additional Concerns

HOURS OF AVAILABILITY

Monday

Time Available

Tuesday

Time Available

Wednesday

Time Available

Thursday

Time Available

Friday

Time Available

Saturday

Time Available

Sunday

Time Available

Printed Name of Person Completing This Form

Services

ABA Therapy

Programs

Service Settings

Intake Paperwork & Form

PERSONAL INFORMATION

PATIENT INFORMATION

RESPONSIBLE PARTY INFORMATION

EMERGENCY CONTACT INFORMATION

INSURANCE INFORMATION

MEDICAL HISTORY

SCHOOL HISTORY

ASSOCIATED SERVICES

CONCERNS

HOURS OF AVAILABILITY

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