We recommend completing the following form on a desktop or laptop computer.

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?*

    ABA Cancellations, Late Arrivals, Late Pickup Policy

    Please carefully read the following document and click to acknowledge that you have read, understand, and agree to abide by the terms of this policy.

    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*