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://app.kindertales.com/waitlist/addinquirylist.php?formid=35MRK6gdp5
Email *
Client First Name *
Client Last Name *
What is the name that this client goes by? *
Date of Birth *
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DD
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Your Full name *
Your Relationship to the client *
Are you the legal guardian of the client? *
Your Telephone number *
Your Email Address *
Street Address *
City *
zip code *
What primary insurance does the client have? *
Please list the full insurance ID number *
Do they have secondary insurance? If so, please list the insurance name *
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 *
Select the primary method of communication for the client. *
What are your main concerns with the client? *
Does the client attend school? If so, what school and what is their schedule? *
Indicate any other services the client currently receives. *
Required
Has the client received ABA services in the past, If so with whom and when? *
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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