Parent/Caregiver Name (*):

Email Address (*):

Child (Client) Name (*):

Client Age (*):

Client DOB (*):

Gender (*): MaleFemaleOther

Home Address:

Primary Phone # (*):

Fax #:

Preferred Method of Contact: PhoneEmailMailFax

Client's School:

Does the Client have a diagnosis of Autism?YesNo
If NO, does the Client have a diagnosis? (please list all diagnoses)

Does the Client have a referral for ABA services?YesNo

Has the Client ever received ABA services?YesNo
If YES, please list dates and previous service provider name:

Is the Client medically stable? YesNo
If NO, please explain current medical concerns:

Does the Client currently take any prescription medications?YesNo
If YES, please list all current medications and dosages:

Is a family member/caregiver willing and able to participate in services?YesNo
Availability (please list days and times of the week that the client and family member/caregiver are available for services):

Client's Primary Care Physician (Please list name, address, and contact information):

Insurance Card (Front):
Insurance Card (Back):

Additional diagnosis and referral documentation from licensed physician:

Primary concern/reason for seeking ABA services?
How did you hear about our services?