Child's Full name

Child's Date of Birth

Parent/Guardian full name

Parent/Guardian Email Address

Parent/Guardian phone number

Home Address, including street, city, state and ZIP

Does the child have an autism diagnosis?

What is your child's availability for participation in ABA therapy?

Mornings between 8:00 am and 12:00 pm Early afternoons between 12:00 pm and 3:00 pm Late afternoons/ Evenings between 3:00 pm and 6:30 pm

Please list days and times your child participates in other therapies (speech, OT, PT, ETC) and days/times in which they are NOT available for ABA sessions that we would need to schedule around. If no other therapies, please type "n/a"

Primary Insurance name:

Primary Insurance ID number:

Does your child have Secondary insurance coverage? If so, please add the company name and member ID Number, otherwise, type "no"

Behavior Concerns: Aggression towards others Please check any behaviors your child has engaged in within the past 3 months

Behavior Concerns: Self Injury Please check any behaviors your child has engaged in within the past 3 months

Behavior Concerns: Property Destruction Please check any behaviors your child has engaged in within the past 3 months

Behavior Concerns: Dangerous Behaviors Please check any behaviors your child has engaged in within the past 3 months

Behavior Concerns: Tantrums Please check any behaviors your child has engaged in within the past 3 months

Behavior Concerns: Other concerning behaviors Please check any behaviors your child has engaged in within the past 3 months

Communication Challenges

difficulty requesting wants or needs difficulty expressing feelings/emotions limited vocabulary difficulty forming sentences difficulty understanding questions requires repetition of instructions needs prompts to respond becomes frusterated when not understood

Please add any additional information you think is important for us to know

Client Intake Questionnaire

Clinic Address

Business Hours