Clinic Intake

* Indicates required fields. It is not recommended to use Safari to fill out this form. Copies of Insurance and Diagnostic Report must be included

Child's Information

Child's Name*

Child's Date of Birth*

Child's Social Security #*

Child's Gender*

Caregiver Information

Caregiver Name*

Relationship to Child*

Email*

Primary Phone #*

Secondary Phone # (optional)

Address*

City*

State*

Zip Code*

Diagnosis

Autism Diagnosis*

YesNo

Secondary Diagnosis (if applicable)

Physician Name*

Physician Contact #*

Specialist Name (if applicable)

Specialist Contact # (if applicable)

Diagnostic Report* (one file only, PDF recommended)

Psychological Evaluation (optional, one file only, PDF recommended)

^{If you need assistance with scanning documents and creating PDF files with your device click here for iphone or here for Android device. If you are unable to upload a document, you can Email the attachment.}

Primary Insurance

Primary Insurance Provider*

Primary Insurance Member ID#*

Primary Insurance* (one file only, PDF recommended, include front and back of card)

^{If you need assistance with scanning documents and creating PDF files with your device click here for iphone or here for Android device.If you are unable to upload a document, you can Email the attachment.}

Secondary Insurance

Secondary Insurance Provider (optional)

Secondary Insurance Member ID# (optional)

Secondary Insurance (optional, one file only, PDF recommended)

^{If you need assistance with scanning documents and creating PDF files with your device click here for iphone or here for Android device. If you are unable to upload a document, you can Email the attachment.}

Child's Behaviors (choose one per category)

Aggression* (choose one)
DailyWeeklyMonthlyRarely/Never

Refusals* (choose one)
DailyWeeklyMonthlyRarely/Never

Self-Injurious Behavior* (choose one)
DailyWeeklyMonthlyRarely/Never

Elopement* (choose one)
DailyWeeklyMonthlyRarely/Never

Property Destruction* (choose one)
DailyWeeklyMonthlyRarely/Never

Disrobing* (choose one)
DailyWeeklyMonthlyRarely/Never

Tantrum* (choose one)
DailyWeeklyMonthlyRarely/Never

Additional Behavioral Information

Child's Verbal Behavior*
VerbalNon-Verbal

Child's Strengths* (minimum length is 100 characters)

Further Details* (minimum length is 100 characters)

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