Client Intake Form

Client Intake Form

This form is to be completed by the Parent/Guardian of the client of Personal Growth Services prior to the initial consultation visit. Please be sure to submit an official diagnosis of ASD and/or assessment as well as a copy of your insurance information along with this form. If the diagnostic report is older than six months, we will need a letter from the primary care physician supporting the diagnosis.
Client Name (First, Middle, Last)*
Client Date of Birth*

MonthDayYear
Date
Client Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Language Spoken in the Home*
Parent/Guardian Information
Parent/Guardian Name (1)*

First NameLast Name
Parent/Guardian Email (1)*
example@example.com
Parent/Guardian Phone Number (1)*
Please enter a valid phone number.
Parent/Guardian Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name (2)

First NameLast Name
Parent/Guardian Email (2)
example@example.com
Parent/Guardian Phone Number (2)
Please enter a valid phone number.
Insurance Information
Name of Insurance Company*
Name of Policy Holder*
Social Security Number of Policy Holder
Date of Birth of Policy Holder*

MonthDayYear
Date
Insurance Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Phone Number
Please enter a valid phone number.
Member ID*
Group ID

Medical Information
Name of Primary Care Physician
Primary Care Physician Phone Number
Please enter a valid phone number.
Primary Care Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Diagnosis
Date of Diagnosis

MonthDayYear
Date
Name of Diagnosing Provider
Medical Treatment History
Are there any other medical conditions the client has which may impact the treatment of ASD or may require staff to respond differently to symptoms? If yes, please explain.*
History of Infectious Disesase*
Known Allergies*
Has the client ever been hospitalized for behavioral concerns?*

YesNo
If yes, please explain
Family Medical and Behavioral Health History
Please describe birth history including any complications. Please describe pregnancy history.*
Birth Weight*
Weeks Gestation*
How do you rate your child's overall health?*

ExcellentVery GoodGoodNot Very GoodPoor

Educational Information
Name of School District
Classroom Type
Grade
School Phone Number
Please enter a valid phone number.
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does the child receive special education services at school? If yes, please list services they receive at the school.*

Client Information
What are your child's strengths?*
What are your family's strengths?*
What are your child's areas of need?*
Some activities I like to do with my child are:*
I wish I could enjoy the following activities with my child but they are not possible at the moment:*
Have you observed overall improvement in your child's behavior and ability to learn new skills? Please explain:*
In what area/skills would you like parent training and support?*
Is there anything else that you would like to discuss? Please write any questions or concerns that you have regarding your child and ABA services.

Past and Current Provider Information
Behavioral Provider Name:
When Did Services Start?
Speech and Language Pathology Provider Name
Speech and Language Pathology Provider Phone Number
Please enter a valid phone number.
Occupational Therapy Provider Name
Occupational Therapy Provider Phone Number
Please enter a valid phone number.
Other Therapy Provider Name
Other Therapy Provider Phone Number
Please enter a valid phone number.
Reasoning of Other Therapy Provider

Are you looking for in-home or center based services?*

In HomeIn CenterHybrid (some of both)
Availability For Services
Monday Time*   to   Time*
Tuesday   Time*   to   Time*
Wednesday   Time*   to   Time*
Thursday   Time*   to   Time*
Friday   Time*   to   Time*

Upload Required Documents for Services
Upload Front and Back of Insurance Card, Diagnostic Report, Letter from Physician

Cancelof
Should be Empty:

Parent/Guardian Information