Submission ID
EAS Full Intake Form
Child's Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Diagnosis
*
-
Month
-
Day
Year
Date
Diagnostic Clinician
*
First Name
Last Name
Diagnostic Clinician's Phone Number
*
Please enter a valid phone number.
Primary Care Doctor
*
First Name
Last Name
Primary Care Doctor's Phone Number
*
Please enter a valid phone number.
Does your child have any allergies?
*
Yes
No
Please list any known allergies.
Does your have any known medical conditions or take any medication?
*
Yes
No
Please describe your child's medical condition(s) and/or medication your child is taking.
Behavioral health history (history of treatment, interventions, and response to treatment)
*
Parent/Guardian Information
Parent/Guardian Name
*
First Name
Last Name
Please list any additional parents/guardians.
Marital Status
Please Select
Single
Married
Divorced
Widowed
Other
Email
*
example@example.com
Primary Phone Number
*
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
Please describe any legal issues that may be relevant to your child's therapy (e.g. divorce)
Insurance Information
Insurance Type
*
Private Insurance
Medicaid
Self-Pay
Insurance Provider Name
Plan Name
Member ID
Group ID
Copy of Insurance
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Additional Information
If necessary, are you willing to remove your child from school (e.g. send them late, bring them home early) or from other current obligations to accommodate therapy provision?
Please discuss any religious, spiritual or cultural considerations you feel may impact therapy provision.
Have you had an ABA therapy consultant in the past? If so, please indicate the previous company and your reason for leaving.
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