New Client Intake Questionnaire 
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Email *
Child's First and Last Name  *
Child's Date of Birth *
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Name of person filling out the form (first and last) *
Relationship to child *
Best Phone Number *
Preferred way of communication  *
Current mailing address *
Preferred center location  *
Preferred hours of therapy *

How many hours of therapy are you interested in per week?

Please Note:
The required hours for ABA therapy are determined based on recommendations from a Board Certified Behavior Analyst (BCBA) and are tailored to maximize success in therapy. These recommendations take into account various factors, including the client’s individual needs, doctor’s recommendations, scheduling availability, and observed progress. Additionally, insurance coverage may influence the number of therapy hours approved for each client. *
Does your child have a current Autism diagnosis by a doctor?  (within the last 3-5 years) *
If yes, please provide the name of the doctor and the date the diagnosis was received.
Note: An official diagnosis must be provided by a Neurologist, Psychologist, or Developmental Pediatrician. If you do not have a diagnosis, please indicate "None."
 *
Has your child received ABA therapy in the past?  *
How long has your child been receiving ABA therapy and where are they receiving services? Please mark 0 if your child has never received ABA before. *
Please list all people currently living in the home. *
Does your child attend school or other therapy? *
Please list the name of the school and grade if applicable that your child attends or will attend.  *
What type of classroom setting is your child currently in? *
My child is insured by the following insurance company *
Please list any medical diagnosis that your child has. *
Please list any medications your child is currently on including name, dose, frequency, reason.   *
Please list any allergies your child has. *
Does your child have problems with sleeping? *
Does your child have feeding problems?  Please describe briefly. *
Is your child potty trained? *
What is your child's primary communication method?  *
How does your child make requests? *
Briefly describe how your child communicates their wants and needs. *
Does your child engage in any of the following behaviors? *
Required
List any of your child's preferred people, places, or things. *
List any of your child's non preferred people, places, or things. *
How does your child express positive and negative behaviors? List both. *
What are your child's greatest strengths? *
What are some of your child's weaknesses that you would like to see addressed at ABA? *
Does your child make spontaneous comments about the environment?  *
The following questions will help us learn more about your childs social skills in a variety of areas.  Some of the things we work on in a social setting: play & leisure skills, cooperation & teamwork, sportsmanship, speaking & listening, perspective taking, social conflict resolution, friendships and relationships, self advocacy, non-verbal communications, self regulation and managing emotions, as well as group learning.
Does your child respond to comments made by others? *
How does your child respond when you or others call their name? *
How does your child respond when told to do something? (throw that in the trash, get dressed, clap hands...) *
How would your child respond to an unexpected sound made by a person in their environment such as a loud sneezing sound, or "OUCH/WOW".  How would they respond? *
How does your child respond to smiling, laughing , or others positive expression while you are interacting with them?  *
If you child engages in a behavior you disapprove of and you shook your head "NO" or made a serious "Stop that" type face, how would your child respond? *
Please list any additional things you would like us to know about your child.
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