ABA Therapy Intake

Client Full Name

Client Preferred Name

Client Date of Birth

Your Full Name

What is your relationship to the client?

Are you the legal guardian of the client?
YesNo

Your Phone Number

Your Email Address

Street Address

City

Zip Code

What primary insurance does the client have?

Please list the full insurance ID number

Do they have secondary insurance? If so, please list the insurance name

Does the client have an autism diagnosis?
YesNo

Do you have a hard copy of the Autism diagnosis from the diagnosing physician?
YesNo

Please list any other diagnoses of the client

Select the primary method of communication for the client.
VerbalGesturesSign LanguagePECS (or another device)No Functional Communication

What are your main concerns with the client?

Which Programs are you interested in?
In-HomeEarly LearnersElementary PrepHybrid ProgramSupported LearningSocial SkillsMultiple Programs (list below)Other (list below)
If multiple programs, list here

If other, list here

Does the client attend school? If so, what school and what is their schedule?

Indicate any other services the client currently receives.
Speech TherapyMental Health ServicesOccupational TherapyOther

Has the client received ABA services in the past, If so with whom and when?

Which days would the client be available for services (Company policy requires a minimum of 6 hours per week)?
MondayTuesdayWednesdayThursdayFriday

What times during those days would the client generally be available for services?
Morning (sometime between 8 AM and Noon)Afternoon (sometime between Noon and 3 PM)Evening (sometime between 3 PM and 8 PM)

Parent participation is essential to what we do at Catalyst. Are you willing to participate in services and implement treatment plans and behavior plans that our Board Certified Behavior Analysts create?
YesNo

How did you hear about us?
---DoctorFamily/FriendBillboardWebsiteInternet SearchOther

Other:

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