ABA Therapy Intake Form Child Information Child's First Name * Child's Last Name * Child's Date of Birth * Gender Male Female Other Parent/Guardian Information Parent/Guardian First Name * Parent/Guardian Last Name * Phone Number * Best Email * Address Line 1 * Address Line 2 * City * State * Zip Code * Parent/Guardian Marital Status * Single Married Divorced Widowed Other Who holds legal custody / medical decision-making authority for the child? * Both parents (Joint Legal Custody) Mother only Father only Legal Guardian / State Placement Other Are there any legal custody agreements or court orders regarding medical care? * Yes No Secondary Parent / Authorized Guardian Info Name Phone Email Medical and Diagnostic Information Does your child have an Autism Diagnosis? * Yes No Does your child have any other diagnoses? * Yes No Is your child currently receiving ABA Therapy? * Yes No Pediatrician Information Name * Phone * Email * Insurance Information Primary Insurance Name * Secondary Insurance Name Availability and Service Preferences Availability for Services * Monday Tuesday Wednesday Thursday Friday Weekends Desired Service Hours (During the week) Morning Afternoon Evening Preferred Location of Services * Home Center School Daycare Other File Uploads Front of Insurance Card(s) * Drop a file here or click to upload Choose File Maximum file size: 33.55MB Back of Insurance Card(s) * Drop a file here or click to upload Choose File Maximum file size: 33.55MB Autism Diagnosis Report (CDE) * Drop a file here or click to upload Choose File Maximum file size: 33.55MB Custody Agreement / Legal Order Drop a file here or click to upload Choose File Maximum file size: 33.55MB * I authorize One on One Behavioral Services to verify my insurance coverage and benefits (including deductibles, copays, and out-of-pocket costs) for Applied Behavior Analysis (ABA) services. Submit If you are human, leave this field blank. Intake Form Child's Name * Date of Birth * Relationship to Child * Parent First, Last Name * Parent Phone Number * Best Time to Call * Address * Are you looking for services or employment? * Primary Language * Best Email * List All Days & Times Available for ABA Sessions * Insurance Company * Insurance Member ID/Policy Number * Insured Under (Subscriber) * Subscriber's Date of Birth * How Did You Hear About Us * I authorize One on One Behavioral Services to verify my insurance coverage and benefits (including deductibles, copays, and out-of-pocket costs) for Applied Behavior Analysis (ABA) services. Captcha Submit If you are human, leave this field blank.
