Information Needed for ABA Intake

Please complete the exact intake information listed below.

Important: A formal ASD diagnosis report is required for insurance processing.

1. Client & Family Information

Child's full name *

DOB *

Gender

Parent/guardian names *

Parent/guardian contact information *

Primary language(s) spoken at home

Custody information (if applicable)

Emergency contacts

Formal ASD diagnosis report (required for insurance) *

Date of diagnosis

Diagnosing provider

Additional diagnoses (ADHD, speech delay, genetic conditions, etc.)

Medical history (birth history, surgeries, allergies, medications)

Insurance provider *

Member ID *

Copy of insurance card (front/back) *

Current school/IEP information (if applicable)

Prior ABA/speech/OT services (if any)

Challenging behaviors (frequency, intensity, triggers)

Communication level (vocal, AAC, gestures)

Social/play skills

Daily living skills (toileting, dressing, feeding)

Sleep, feeding, toileting concerns

Top parent goal 1 *

Top parent goal 2 *

Top parent goal 3 *

Preferred schedule and availability *

Location of services (home, school, center, community) *

Consent for observation in school or other settings *