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 First Last Nickname? Date of Birth* Month Day Year Parent Name* First Last Parent Phone Number*Parent Email Address* Tell Us What Brought You HereDescribe your main concerns and what led you to seek/be referred to ABA therapy, noting when these first arose and where issues are most likely to occur.*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 ChildRelated Condition/ Diagnosis? Add RemoveTo add more than one, click plus tab to the right. If none, skip this one. Describe any difficulties with sucking, swallowing, chewing, eating different textures, etc.*Child's Strengths, Favorites, and AversionsIdentifying strong motivators (and knowing their dislikes/triggers) helps us shape the most effective ABA therapy sessions.Describe your child’s strongest skills and personality traits. What makes your child special, interesting, and awesome?*Favorite Foods*Food Aversions (if you can, indicate what it is they appear to dislike - the color, texture, smell, taste, size, etc.)*Aside from certain foods, what have you identified as their dislikes or meltdown triggers? (Examples: Haircuts; bathing; certain types of fabric; transitions from one activity to the next; large crowds; loud noises, etc.)*Favorite Hobbies/Activities*Favorite toys, movies, shows, characters, books, etc.*If you have additional clinical or educational documentation pertaining to your child's diagnosis, treatment, or education that would be helpful for our ABA therapists to know and that you did NOT already upload on the main Intake Form for All New Patients, please upload here. Drop files here or Select files Max. file size: 195 MB. Tell us what days, times, and location would be ideal for ABA Therapy. (Ex: Anytime Monday-Thursday, 8a-3p, in-clinic)*While we cannot guarantee our availability will match your desired schedule exactly, we'll do our best! How did you hear about us?* Online search Social media Brochure, flier, business card, or other printed media Recommended by friend or family member Referred by physician or other healthcare provider Other If you answered "other" to the previous question, please describe: Parent SignatureParent Electronic Signature* First Last 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* Month Day Year Δ