A B A T H E R A P Y

Applied Behavior Analysis

An evidence-based treatment to support your child acquire skills they need to be successful in school, in the community, and at home

ABA Intake Form

For New Patients

Your Name

Email Address

Phone Number

Insurance Type

Diagnosis

Pediatrician's Name

Pediatrician's Phone Number

Child's Name

Child's Date of Birth

Address

Insurance ID

Name of School (if in school)

Services received in school:

Reason for Requesting Services

Other Private Services Received

Speech Therapy

Occupational Therapy

Physical Therapy

Other

Current Medications & Dosage (if applicable)

Availability for Session: ABA sessions typically occur 5 days per week and last 2-3 hours, and we have three time blocks available. Please select the time block that your child’s schedule would best fit in.

A: 9:00 AM-12:30 PM

B: 1:00 PM-4:30 PM

C: 5:00 PM - 7:00 PM

Other Information: Please include any information you think we should know about your child that we haven't asked you about in this intake form.

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

A B A T H E R A P Y

Applied Behavior Analysis

ABA Intake Form

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