Intake Form Client DiagnosisNameAgeDate of Birth Date Format: MM slash DD slash YYYY GenderMaleFemaleDate of Diagnosis Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Current DiagnosisDiagnosed ByParents / GuardianMother's NameFather's NameDate of Birth Date Format: MM slash DD slash YYYY Date of Birth Date Format: MM slash DD slash YYYY Occupation / EmployerOccupation / EmployerMobile Phone NumberMobile Phone NumberWork Phone NumberWork Phone NumberHome Phone NumberHome Phone NumberEmail Address Email Address SiblingsNameAgeDiagnosis?NameAgeDiagnosis?NameAgeDiagnosis?School InformationName of SchoolSchool Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code School Contact InformationTeacher's NameServices Received At School Occupational Therapy Physical Therapy Speech Therapy Behavior Plan Other Please Describe OtherPrimary InsuranceSubscriber's NameSubscriber's Date of Birth Date Format: MM slash DD slash YYYY Subscriber's EmployeerCarrierCase ManagerGroup #ID #Phone #Fax #Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Secondary InsuranceSubscriber's NameSubscriber's Date of Birth Date Format: MM slash DD slash YYYY Subscriber's EmployerCarrierCase ManagerGroup #ID #Phone #Fax #Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Medicaid / Medical AssistanceID #TypeName of Service CoordinatorCountyRegionStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificPhone #Psychological HistoryHas your child ever had a psychological evaluation?YesNoWhoWhenCopy AvailableYesNoFindings / RecommendationsChild's Medical HistoryChild's Primary DoctorPractice NamePractice Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberFax NumberHas your child ever had any operations, serious illnesses, injuries, hospitalization, allergies or other serious medical concerns?YesNoPlease explain whyPlease list any medications your child is currently takingDoes your child have any vision or hearing problems?Family Medical HistoryIs there any family medical history you would like us to know and which might relate to the services you seek for your child?YesNoPlease describeLegal IssuesAre there any legal issues concerning your child or family that night affect our ability to provide services?YesNoPlease describeBehavior HistoryDo you have any behavior concerns for your child?YesNoHas your child expressed high-risk behavior including, but not limited to, injury to self or to others?YesNoPlease explainCultural or Religious ConsiderationsAre there any cultural or religious factors of which you would like us to be aware when working with your child and family? If so, please feel free to describe such consideration below:Which Therapies Are You Interested In? 1:1 ABA Social Skills Groups Occupational Therapy Speech Therapy Please list goals / topics you would like addressed for 1:1 ABAPlease list goals / topics you would like addressed for Social Skills GroupsPlease list goals / topics you would like addressed for Occupational TherapyPlease list goals / topics you would like addressed for Speech TherapyPlease provide copies of the following documentation (as applicable)Physician Diagnosis of AutismInsurance CardIEP504 PlanImmunization RecordPsychological EvaluationSpeech EvaluationOT EvaluationPT EvaluationBehavior PlanDriver's LicensePhoneThis field is for validation purposes and should be left unchanged.
