New Patient Forms

ABA Intake Form

CHILD INTAKE FORM ABA

Child Intake Form for Behavior Therapy/ABA

Child's Information
Child's Name*
Gender*
Child's Current Age*
Date of Birth*
Date Format: MM slash DD slash YYYY
Name of School
Grade*
Do You Have a Primary Care Physician?*
Primary Care Physician's Name
Primary Care Physician's Phone Number
Primary Care Physician's Address
Street Address Address Line 2 City State ZIP Code
Is your child currently being seen by a behavioral health technician?*
Describe your main concerns. Include when problems were first noticed, who noticed and where problems occur.*
Why are you seeking services for your child?*
Has your child’s physician noticed these concerns? If yes, what recommendations did he/she make?*
How did you learn about us?*
Are you currently utilizing any community resources (e.g. support groups, social groups, social services, school-based services or other social supports)?*
List all other services your child has received, including counseling; psychiatry; physical, speech, occupational or ABA therapy, etc. If none, skip..
Type of Service Dates/Ages Name of Provider

To list multiple services/providers, click the plus tab on the right to create another row.
Family Information
With whom does your child live? (Check all that apply.)*
- Biological parent(s)
- Adoptive parent(s)
- Grandparent(s)
- Legal guardian(s)
- Sibling(s)
- Other
List all family members who live with your child.*
Name Age Relation to the child

To add additional family members, click the plus tab to the right.
Please list family pets in the home. If none, skip.
Type Name

To add more than one pet, click the plus tab to the right.
Parent Information
Parent 1 Name*
First Last
Parent 1 Gender
Parent 1 DOB*
Date Format: MM slash DD slash YYYY
Parent 1 Address*
Street Address Address Line 2 City State ZIP Code
Parent 1 Phone No. 1*
Parent 1 Phone No. 2
Parent 1 Email Address*
Enter Email Confirm Email
Parent 1 Preferred Method of Contact*
Parent 1 Employer*
Parent 1 Job Title*
Parent 2 Name
First Last
Parent 2 Gender
Parent 2 DOB
Date Format: MM slash DD slash YYYY
Parent 2 Address
Street Address Address Line 2 City State ZIP Code
Parent 2 Email
Enter Email Confirm Email
Parent 2 Phone No. 1
Parent 2 Phone No. 2
Parent 2 Preferred Method of Contact
Parent 2 Place of Employment
Parent 2 Job Title
Are there family circumstances that would be helpful to share with your child’s therapist such as medical issues or legal issues? (e.g., custody arrangements)*
Are there any other languages spoken in the home? If yes, which language(s) and how often?*
Do any other family members any diagnosis or known medical conditions/ disorders? (e.g., ADHD, autism)
Relation to Child Related Condition/ Diagnosis?

To add more than one, click plus tab to the right.
Child's Health History
Describe your pregnancy, including any complications.*
Describe your labor/delivery, including any complications.*
Type of birth (check all that apply):*
- Spontaneous (not induced)
- Induced
- Vaginal
- C-section
Birth Place (hospital, etc.)*
Birth Attendant Name (physician, midwife, etc.)
Gestational Age (in weeks)*
Birth Length*
Birth Weight*
NICU?*
If your child stayed in the NICU, for how long?
Were there any complications after birth or during the first few weeks? (Check all that apply.)*
- Difficulty breathing
- Difficulty feeding
- Birth defect
- Jaundice
- Seizure
- Other
- None
Has your child's hearing been tested?*
If your child's hearing has been tested, when and where?
If your child's hearing has been tested, what was the determination?
Does your child have an infectious or communicable disease?*
If your child does have an infectious or communicable disease, please describe.
List any environmental or food allergies, please include adverse reactions to allergen.*
List any routine medications your child is currently taking or has taken long term.
Medication Doses Frequency Side Effects

To add more than one medication, click the plus tab to the right.
Describe any other conditions or diagnoses identified by your child’s doctor or other professionals.
Please list any spiritual or cultural variables that may impact treatment that we should be aware of.
Click all that apply.*
- Breastfed
- Formula Fed
- Both
If your child was breastfed, for how long? ( __ Months to __ Months.)
If your child was formula fed, for how long? ( __ Months to __ Months.)
At how many months-old did your child begin using a sippy cup? (If still not in use, skip.)
At how many months-old did your child begin using an open cup? (If still not in use, skip.)
At how many months-old did your child begin using a straw? (If still not in use, skip.)
At how many months-old did your child begin using utensils? (If still not in use, skip.)
Describe any difficulties with sucking, swallowing, chewing, eating different textures, etc.*
FAVORITE FOODS*
FOOD AVERSIONS*
Child's Educational Information
Name of School
Classroom Type
Teacher/Grade
School Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Does your child have an IEP?*
If yes, please provide us with a copy of the most recent IEP and ETR.
Child's Strengths and Favorites
Describe your child’s strongest skills and personality traits. What makes your child unique?*
FAVORITE ACTIVITIES / HOBBIES*
FAVORITE TOYS
FAVORITE MOVIES
FAVORITE BOOKS
Parent Electronic Signature*
First Middle Last
Today's Date*
Date Format: MM slash DD slash YYYY

Child Emergency Contact Information

CHILD CARE EMERGENCY CONTACT INFORMATION

Child's Name*
First Last
Child's Date of Birth*
Date Format: MM slash DD slash YYYY
Child's Address*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian Name*
First Last
Parent Home/Cell Phone Number*
Parent Work Number*
Parent Email Address*
Enter Email Confirm Email
Parent Home Address*
Street Address Address Line 2 City State ZIP Code
Place of Employment*
Work Title
Department
Work Contact Person (who usually knows your whereabouts)
Work Contact's Phone Number
Parent/Guardian Name
First Last
Parent Home/Cell Phone Number*
Parent Work Number
Parent Email Address
Enter Email Confirm Email
Parent Home Address
Street Address Address Line 2 City State ZIP Code
Place of Employment
Work Title
Department
Work Contact Person (who usually knows your whereabouts)
Work Contact's Phone Number
Emergency Contacts
Person to contact when attempts to reach parents are not successful and who may pick up the child.
Emergency Contact No. 1*
First Last
Emergency Contact No. 1 Home/Cell Phone*
Emergency Contact No. 1 Work Phone
Emergency Contact No. 2*
First Last
Emergency Contact No. 2 Home/Cell Phone*
First Last
Emergency Contact No. 2 Work Phone
Persons Authorized to Pick Up the Child
We must have written permission for anyone other than parent/ guardian to pick child up from the center.
Name No. 1
First Last
Phone
Name No. 2
First Last
Phone
Name No. 3
First Last
Phone
Name No. 4
First Last
Phone
Child's Medical Emergency Contact
Physician's Name*
First Last
Physician's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Physician's Phone #*
Dentist's Name (child's or parent's)*
First Last
Dentist's Address*
Street Address Address Line 2 City State ZIP Code
Dentist Phone Number*
Child's Health Insurance
Name of Insurance Plan*
Certificate Number (or ID) #*
Group #*
Policy Holder’s Name
First Last
Special Conditions, Disabilities, Allergies, or Medical Information for Emergency Situations*
Parent/Legal Guardian Consent and Agreement for Emergencies
Parent/Guardian No. 1 Consent Agreement*
As parent/legal guardian, I give consent to have my child receive first aid by facility staff, and, if necessary, be transported to receive emergency care. I understand that I will be responsible for all charges not covered by insurance. I agree to review and update this information whenever a change occurs and at least once a year.
Parent Guardian No. 1 Electronic Signature*
First Last
Today's Date*
Date Format: MM slash DD slash YYYY
Parent/Guardian No. 2 Consent Agreement
As parent/legal guardian, I give consent to have my child receive first aid by facility staff, and, if necessary, be transported to receive emergency care. I understand that I will be responsible for all charges not covered by insurance. I agree to review and update this information whenever a change occurs and at least once a year.
Parent Guardian No. 2 Electronic Signature*
First Last
Today's Date
Date Format: MM slash DD slash YYYY

Photo Release

Photo Release for Social Media, Marketing & Media

YES, I give consent to use photos of my child on ALL Social Media sites, marketing materials.
I hereby grant to Therapy and Wellness Connection LLC, the right to interview, Photograph, and/or video record myself or my child and use the photo and/or other digital reproduction of me in any and all of its publications and in any and all other media social/media, whether now known or hereafter existing. I understand and agree that these materials will become the property of Therapy and Wellness Connection LLC and will not be returned. Additionally, I waive any right to any compensation arising or related to the use of the photograph.
No, I do NOT give consent to use photos of my child on ANY Social Media sites or for marketing materials.
I agree to the privacy policy.
Child's Name*
First Middle Last
Parent's Name*
First Middle Last
Date*
Date Format: MM slash DD slash YYYY

Insurance Intake Form

Client/Child's Name*
First Middle Last
Home Address*
Street Address Address Line 2 City State ZIP Code
Insurance Information
Are you using insurance benefits to cover all or part of therapy services?*
If you are using insurance, indicate whether you are:
Insurance Company Name*
Insurance Company Street Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Company ID #
Group #
Policy Holder's Name
First Last
Policy Holder's Date of Birth
Date Format: MM slash DD slash YYYY
Policy Holder's Employer
Co-Pay Amount
Have you reached your deductible?
Co-Insurance
Insurance Information Release
Consent to Release Insurance Information
By clicking this box, I hereby authorize Therapy and Wellness Connection to release to my insurance company, any information regarding this dx which is required to process my claims.
Assignment of Insurance Benefits:
Consent for assignment of insurance benefits.
By clicking this box, I hereby assign my insurance benefits to Therapy and Wellness Connection.
Today's Date*
Date Format: MM slash DD slash YYYY
Name of person filling out this form.*
First Last

Therapy & Wellness Connection Policies & Procedures

CHILD INTAKE FORM ABA

Child's Information

Family Information

Parent Information

Child's Health History

Child's Educational Information

Child's Strengths and Favorites

CHILD CARE EMERGENCY CONTACT INFORMATION

Emergency Contacts

Persons Authorized to Pick Up the Child

Child's Medical Emergency Contact

Child's Health Insurance

Parent/Legal Guardian Consent and Agreement for Emergencies

Therapy & Wellness Connection Policies & Consent to Therapy Services

Client Communication

Photo Release for Social Media, Marketing & Media

Insurance Intake Form

Insurance Information

Insurance Information Release

Assignment of Insurance Benefits:

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About Us

Type of Service	Dates/Ages	Name of Provider

Name	Age	Relation to the child

Type	Name

Relation to Child	Related Condition/ Diagnosis?