ABA Patient Intake Form

Adolescent ABA Therapy patients must be within the age range of 10 - 18 years of age.

A diagnosis letter specifying a diagnosis code of F84.0 (Autistic Disorder) is required in order to move forward with the intake process.
The patient must be diagnosed as either level 1 or level 2 to be considered for treatment. Level 2 patients are evaluated on a case by case basis. (view autism levels & matrix info)
Patients who have had previous ABA Services or are currently receiving such from another provider are required to complete an ABA assessment. The ABA assessment takes between 1-2 hours and provides the insight required by the assigned BCBA to create an effective Treatment Plan for the client.

I understand that the patient must be between the ages of 10-18 and have a diagnosis letter stating diagnosis code F84.0 (Autistic Disorder). The patient must also be diagnosed as level 1 or level 2 to be considered for treatment. Level 2 patients are evaluated on a case by case basis.

I confirm that the patient meets the requirements stated.

Select the ABA service that you are interested in

Requested number of days per week for ABA therapy

Requested service hours

Patient's Name

First Name

Last Name

Patient's DOB

YYYY

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

First Parent/Caregiver's Name

First Name

Last Name

Relationship to patient

First Parent/Caregiver's Phone

(###)

###

####

First Parent/Caregiver's Email

Second Parent/Caregiver's Name

First Name

Last Name

Relationship to patient

Second Parent/Caregiver's Phone

(###)

###

####

Second Parent/Caregiver's Email

Does the patient have a diagnosis letter stating diagnosis code F84.0 (Autistic Disorder)

Is the patient currently receiving ABA Therapy from another provider?

Is the patient covered by medical insurance?

Name of medical insurance company

Medical Insurance Policy Holders Name

Medical Insurance Policy Holders DOB

YYYY

Medical Insurance Policy Holders Employer

Medical Identification Number

Does the patient receive funding from Step Up For Students?

If yes, how much funding does SUFS provide?

Does the patient have any other conditions?

If additional conditions exist, please list and explain.

Is the patient currently enrolled in school?

If enrolled in school, please list the name of the school and current grade level.

Please provide a summary of your needs/expectations for your child for ABA therapy.