Client Intake Updated Sept2022

New Client Application - Acclaim Autism

Home & community based ABA therapy in Pennsylvania & Southern California. To help us match your child with an appropriate therapist or secure a place on the waitlist, validate insurance and keep things moving, please complete as much information as possible on this intake form. This form is HIPAA-compliant. By completing this online form you agree to receive electronic communication from us.
For all Pennsylvania inquiries:

(888) 805-8206

info@acclaimautism.com

For all California inquiries:

(800) 689-8675

SoCalSocialSkills@acclaimautism.com
Parent / Legal Guardian Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Communication Preference*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Relationship to Patient*

ParentLegal GuardianOther
Are You Legally Authorized to Consent for This Patient's Healthcare?*

YesNo
Page 1 of 3

Insurance Information
Picture (Front of Insurance Card(s) in the PATIENT's NAME)

Browse Files

Cancelof
Picture (Back of Insurance Card(s) in the PATIENT's NAME)

Browse Files

Cancelof
Insurance Policy Holders Date of Birth

MonthDayYear
Insurance Policy Holders Date of Birth
will remove. incorrect data type
Insurance Information and Authorization (all check boxes will be required if you want us to pursue insurance as payment method)

I authorize my insurance provider(s) listed above to make payments directly to Acclaim Autism for services rendered.I understand that a copy of my insurance card (front and back) will be retained in my client/patient file for billing purposes.I agree that private information may be shared with my insurance carrier for billing purposes.I understand that if I do not want information shared that I may submit specific direction to Acclaim Autism
Private Billing Information, if applicable (only if paying cash, not using insurance)

I am a private pay client and acknowledge it is my personal responsibility to pay for services.
Page 2 of 3

Patient Information
First Name*
Last Name*
Gender*
Date of Birth*

MonthDayYear
mm/dd/yyyy
Please Check All That Apply

Diagnosed with Autism Spectrum Disorder (ASD) or similar nameAttends SchoolReceives ABA Therapy in SchoolAlready Receives ABA Therapy Outside SchoolWorking with a Social WorkerWorking with a Speech Language PathologistHas a Wellness Recovery Action Plan (WRAP)Underwent a Bright Futures Screening
Interested Services:

Individual ABASocial Skills GroupSummer CampParent Training / Support
Summer Camp

Acclaim West Chester, PA LocationAcclaim Jenkintown, PA LocationThird Party Camp in PA (YMCA, or other)Third Party Camp in CA (YMCA, or other)Other
What Are Some Goals That ABA Can Help With?
List Food Allergies and/or Medication Being Taken, or N/A:*
List Other Medical Providers (Name, Type, Contact Info, Schedule):*
If The Patient Had ABA Before, Please List Name & Contact Info For The Provider:
School or Daycare Contact Information (or N/A):*

Availability for Services:

Availability for Services:*
Primary Care Provider (Name):
Primary Care Provider (Phone):
Please Upload A Copy of The Psychological Evaluation (Diagnosis)

Browse Files

Cancelof
Please Upload A Copy of Individualized Education Program (IEP), if you have one

Browse Files

Cancelof
Company Name
Lead Source
Status
Attachments Folder
Page 3 of 3
Should be Empty:

New Client Application - Acclaim Autism