Step 1 of 6

ABA Services Intake Form

Client/Child's Name *

Date of Birth *

Gender

MaleFemale

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Primary Language(s) Spoken *

Parent/Guardian Information

Guardian Name *

Relationship to Client *

Phone Number *

Email Address *

Guardian Name (2nd)

Relationship to Client (2nd)

Phone Number (2nd)

Email Address (2nd)

Emergency Contact

Emergency Contact (Name/Phone) *

Step 2 of 6

Education History

Is the client currently enrolled in *

DaycareSchoolNot Yet Enrolled

Name of School & Grade Level

Name & Address of Daycare

Will your child be transitioning out of daycare and into a school within the next 6 months?

YesNo

Name of School

Insurance Coverage

Name of Primary Insurance *

Primary Insurance ID # *

Name of Secondary Insurance

Secondary Insurance ID #

Upload photo(s) of your insurance card

Referral Information

Select

Who referred you to ABA services?

Physician/DoctorPediatricianSchoolTherapist/CounselorFamily or FriendOther

Please specify how you were referred

Step 3 of 6

Diagnosis

Does the client have a prior diagnosis?

YesNo

Select

Has the client been formally diagnosed with any of the following?

Autism Spectrum Disorder (ASD)Attention-Deficit/Hyperactivity Disorder (ADHD)Intellectual DisabilitySpeech/Language DelayAnxietyHas Never Been DiagnosedOther (please specify)

Other

What was the date of the client's original diagnosis?

When was the client's most recent evaluation?

Diagnosing Professional (Doctor, Psychologist, etc.)

Additional Diagnoses (if applicable)

Upload past evaluations (optional)

Medical History

Select

Any significant medical history or ongoing health conditions?

SeizuresSensory processing issuesSleep disturbancesChronic illnessAllergiesMedication regimen (please list medications)Other medical concerns

Medication regimen (please list medications)

Other medical concerns

Select

Current Therapies/Interventions

Occupational TherapySpeech TherapyPhysical TherapyCounseling/TherapyABA TherapySocial Skills GroupsMedicationNoneOther

Place of Service and Date of Services *

Please specify other current therapy/intervention

Step 4 of 6

Behavioral Concerns

Types of behaviors of concern *

Aggression (e.g., hitting, biting)Self-injurious behaviors (e.g., head-banging)Property destructionNon-compliance (refusal to follow directions)Tantrums/MeltdownsDifficulty transitioning between activitiesDisruptive vocalizations (e.g., screaming)Elopement (running away)Stereotypic behaviors (e.g., hand-flapping, rocking)Other

Other

Frequency and Duration of Concerns (e.g., how often do these behaviors occur and how long do they last?) *

Where are behaviors occurring? *

HomeSchoolCommunity

Current Functioning

Does the client engage in social interaction with peers

YesNo

How does the client typically engage with others?

Does the client have difficulty with peer relationships?

YesNo

Please explain

Communication Skills

Does the client use verbal communication?

YesNo

If no, how does the client communicate? (select all that apply)

Uses AAC deviceNon verbalPoints to items wantedOther

Please explain other communication method

Please describe the client’s level of communication

Daily Living Skills (e.g., eating, dressing, toileting, etc.)

Areas of Strength *

Areas of Difficulty *

Step 5 of 6

Sensory Concerns

Does the client display any sensory issues?

YesNo

Please explain

Examples of sensory areas (select any that apply)

SightsSoundsSmellsTastesTouchBalance (vestibular)Other

Please specify other sensory area

Stimulatory Behaviors

Rocking back and forthHand flappingSpinning in circlesFinger flicking or wigglingRepetitive vocal sounds (humming, repeating words)Pacing or repetitive walking patternsOther

Other

Goals for ABA Services

What are the primary goals you would like to achieve through ABA therapy?

Decrease problematic behaviorsIncrease social skillsImprove communication skillsEnhance daily living skillsBuild academic skillsOther

Other

Are there any specific behaviors or skills you would like therapy to focus on?

Step 6 of 6

Consent and Acknowledgment

I consent to the collection of this information to begin ABA services. I understand that my personal information will be kept confidential according to applicable laws.I agree to receive ABA services in home, school, or community settings, as determined to be appropriate.I understand that these services are not guaranteed.I acknowledge that all services must be approved by insurance.

Full Name *

Date