ABA Therapy Intake Form

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*

Parent Name*

First Last

Parent Phone Number*

Parent Email Address*

Tell Us What Brought You Here

Describe 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 Child

Related Condition/ Diagnosis?

To 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 Aversions

Identifying 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

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 Signature

Parent 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*