Intake Form Intake Form Child's Name * First Child's Last * Last Child's date of birth * Parent's Name * Parent's Name First First Last Last Email * Phone * Does your child have a diagnosis of autism spectrum disorder? * Yes No Diagnosing Doctor or Clinical Psychologist Date of Diagnosis Severity Level Level 1 Level 2 Level 3 Primary Insurance Provider * Blue Cross Blue Shield Medicaid Tricare Cigna Aetna UnitedHealthCare/ Optum Member ID * What days of the week can your child attend therapy? * Monday Tuesday Wednesday Thursday Friday Which time slots is your child available for therapy? * 9:00 AM - 12:00 PM 12:00 PM - 3:00 PM 3:30 PM - 6:30 PM Other scheduling concerns we should know about? Does your child attend school? yes no home schooled What time does your child attend school? Does your child receive support services at school? Please describe. Other therapies your child is currently receiving Speech Occupational Therapy Physical Therapy Early Intervention Play Therapy Counseling OtherOther Has your child received ABA Therapy previously? Yes No When did your child receive ABA and for how long? What are your child's strengths? What behaviors would you like to see improve? Why are you seeking ABA Therapy for your child? If you are human, leave this field blank. Submit Δ