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Client Intake Form
Email address *
Clients name and date of birth *
Your answer
Your name and relationship *
Your answer
Are you the legal guardian of the client? *
Your contact information (Phone number and address) *
Your answer
What medical insurance/s does the client have? *
Your answer
Does the client have an autism diagnosis that you could could provide to us? *
Please indicate any other diagnosis that the client may have. *
Your answer
Select the primary method of communication for the client. *
What is your biggest areas of concern when it comes to the client? (social deficits, severe behaviors, communication problems) *
Your answer
If the client attends school, indicate which school and the hours that they attend *
Your answer
Indicate any other services the client currently receives. *
Required
Has the client received ABA services in the past, If so with whom and when? *
Your answer
Which days would the client be available for services (Company policy requires a minimum of 6 hours per week)? *
Required
What times during those days would the client be available for services? *
Required
Parent participation is essential to what we do at Catalyst. Are you willing to participate in services and implement treatment plans and behavior plans that our Board Certified Behavior Analysts create? *
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