A B A T H E R A P Y

Center-Based ABA Services

Center-Based ABA Intake Form

For New Patients

Your Name

Relationship to child

Email Address

Phone Number

Insurance Type

Diagnosis

Pediatrician's Name

Pediatrician's Phone Number

Child's Name

Child's Date of Birth

Address Line 1 (Street)

Address Line 2 (City, State)

Insurance ID

Name of School (if in school)

Services received in school:

Reason for Requesting Services

Other Private Services Received

Speech Therapy

Occupational Therapy

Physical Therapy

Other

Current Medications & Dosage (if applicable)

Availability for Session: Center-Based ABA sessions are typically provided 5 days per week. We offer half-day sessions for your child. Please select which half-day option works best:

A: 9:00 AM-12:30 PM

B: 1:00 PM-4:30 PM

Other Information: Please include any information you think we should know about your child that we haven't asked you about in this intake form.

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!