Please carefully read and fill out the following form for ABA Therapy.

ABA Therapy Intake

Child Intake Form for Behavior Therapy/ABA

"*" indicates required fields

Child's Name
Date of Birth*
Parent Name*

Tell Us What Brought You Here

Does any other close family member have a known diagnosis or medical condition that is the same or similar to the child's? (i.e., a brother also has a learning disability, a father also has a heart condition, etc.).
Relation to Child
Related Condition/ Diagnosis?
To add more than one, click plus tab to the right. If none, skip this one.

Child's Strengths, Favorites, and Aversions

Identifying strong motivators (and knowing their dislikes/triggers) helps us shape the most effective ABA therapy sessions.
Drop files here or
Max. file size: 195 MB.
    While we cannot guarantee our availability will match your desired schedule exactly, we'll do our best!
    How did you hear about us?*

    Parent Signature

    Parent Electronic Signature*
    By providing this electronic signature, I hereby affirm I am the parent/guardian of the aforementioned child, for whom I am legally authorized to make medical decisions. I agree to each of the above conditions as indicated, and certify all information contained in this form is complete and accurate to the best of my knowledge. I understand that an electronic signature is the legal equivalent of my manual/handwritten signature, and I am agreeing to all terms and conditions as indicated in this form.
    Today's Date*