Intake Form

Emergency Assistance

If this is an emergency, call:

Client Information

First name

Last name

Date of birth

Home Address

Parent or Guardian Information

First name

Last name

Home phone number

Cell phone number

Email address

Relationship to child

Occupation

Emergency Contact Information

Add another emergency contact

Insurance Information

Primary Insurance Name

Policy ID #

Group

Subscriber's Name

DOB

Relation to Patient

Medical History

Primary Care Physician

Date of last physical exam

Address

Office Phone

Current Medical, Developmental, or Behavioral Diagnoses:

Please list any diagnoses your child has received, including the diagnosing provider and approximate date of diagnosis, if known.

Autism Spectrum Disorder (ASD) Diagnosis Has your child received a formal diagnosis of Autism Spectrum Disorder (ASD) from a qualified healthcare professional?

Yes

Currently undergoing an evaluation

Unsure

If yes, please provide the following information:

Date of diagnosis (if known) Name and credentials of diagnosing provider

Upload autism diagnostic report (if available).

Add file

Please upload a file

Parent/Guardian Attestation

I confirm that the information provided regarding my child's autism diagnosis is accurate to the best of my knowledge. I understand that supporting diagnostic documentation may be requested for insurance authorization.

Is your child currently receiving any of these services?

Currently receiving services Previously received services but no longer attends Both current and previous services Never received services

Please provide the following information about your child's services.

Please include the service type, provider or agency name, frequency of services, location (home, school, clinic, or virtual), and approximate start/end dates, if known.

Has your child ever received ABA therapy?

Yes, currently receiving ABA Yes, previously received ABA No, never received ABA

If yes, who provided the ABA services?

Where did your child receive ABA services?

Home

School

Clinic

Community

Virtual

How many hours of ABA therapy did your child typically receive per week?

If ABA services were discontinued, what was the reason?

Examples: Insurance changes, relocation, family decision, provider change, goals met, scheduling difficulties, or other reasons.

Your Child's Needs and Areas of Concern

We want to understand your child's strengths, needs, and the areas where your family may benefit from additional support. Please select any areas that apply. You do not need to select every item.

1.Communication and Social Interaction Select all that apply.

Expressing wants and needs

Understanding language

Social interaction

Play skills

Other

If other, please describe:

2. Behavior and Emotional Regulation

Transitions and changes

Emotional regulation

Aggression

Self-injurious behavior

Impulsivity

Other

If other, please describe:

3. Daily Living and Independence

Toileting

Dressing

Hygiene

Feeding

Sleep

Other

If other, please describe:

4. Sensory and Repetitive Behaviors

Sensory sensitivities

Repetitive movements

Repetitive speech

Restricted interests

Other

If other, please describe:

5. Additional Concerns

Is there anything else about your child's development, behavior, daily functioning, or family priorities that you would like us to know?

Scheduling and Availability

1. What days is your family generally available for ABA services? Select all that apply.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

2. What times are you generally available? Select all that apply.

Morning (8 AM–12 PM)

Early afternoon (12 PM–3 PM)

Late afternoon (3 PM–6 PM)

Evening (6 PM–8 PM)

Flexible

3. Where would you prefer services to take place? Select all that apply.

Home

School

Community

Telehealth (When clinically appropiate)

Open to reccomendations

5. Please share any scheduling restrictions or additional availability information.

For example: school hours, work schedules, transportation limitations, extracurricular activities, or preferred start dates.

When would your family ideally like ABA services to begin?

As soon as services are authorized

Within the next 30 days

Within 1–3 months

Flexible / No specific timeline

Parent Acknowledgment

I confirm that the information provided in this intake form is accurate and complete to the best of my knowledge.

Thank You for Your Interest in Holistic ABA Care!

Thank you for taking the time to complete our Parent Intake Form.

We appreciate the opportunity to learn more about your family and your interest in Holistic ABA Care.

Once your information has been received, we will review your submission and contact you regarding the next steps, which may include an initial consultation, review of insurance benefits, and discussion of the assessment and enrollment process.

Our goal is to provide compassionate, individualized, and family-centered ABA services that respect each child's unique needs, strengths, and individuality.

We look forward to connecting with your family!

Holistic ABA Care LLC
admin@holistabacare.com
609-553-2804

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