ABA Client Intake Form
In addition to this form additional documentation will be needed. If Under the age of 5 and interested in Catalyst Academy please fill out the following form
https://docs.google.com/forms/d/e/1FAIpQLSfTnSJl1t48K69qzi49GQcC81TY5cOAQXZyuPSMWCsG2-5bnw/viewform?usp=sf_link
Email address *
Client First Name *
Your answer
Client Last Name *
Your answer
What is the name that this client goes by? *
Date of Birth *
MM
/
DD
/
YYYY
Your Full name *
Your answer
Your Relationship to the client *
Are you the legal guardian of the client? *
Your Telephone number *
Your answer
Your Email Address *
Your answer
Street Address *
Your answer
City *
Your answer
zip code *
Your answer
What primary insurance does the client have? *
Your answer
Please list the full insurance ID number *
Your answer
Do they have secondary insurance? If so, please list the insurance name *
Your answer
Does the client have an autism diagnosis? *
Do you have a hard copy of the Autism diagnosis from the diagnosing physician? *
Please list any other diagnoses of the client *
Your answer
Select the primary method of communication for the client. *
What are your main concerns with the client? *
Your answer
Does the client attend school? If so, what school and what is their schedule? *
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? *
How did you hear about Catalyst Behavior Solutions *
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