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Intake Form

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Please use the Intake Form below to help us learn about your needs. Our staff will follow up with any questions within 48 hours. Services are available on a first-come, first-served basis and by therapist availability in your location.

Patient Information

Name(Required)
Address(Required)

Daycare Information (If Applicable)

Daycare Address

Contact Information for Responsible Party

Gender

Insurance Information

Name of Insured | Policy Holder(Required)
Please describe the insured's relationship to the patient (e.g., parent, guardian, or other).
Please complete this field only if applicable.
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          Emergency Contact Information

          Emergency Contact Name(Required)
          Please describe Emergency Contact's relationship to the Patient (e.g., Parent, Guardian, other)

          Clinical Information

          Does your child engage in any physical aggression towards others (i.e., Hitting, kicking, biting, scratching, etc.)
          Does your child engage in property destruction (i.e., breaking toys/household items, throwing objects, etc.)
          Does your child engage in any self-injury (i.e., biting self, headbanging, etc.)
          Does your child ever show signs of running away?
          When working with one of our behavior technicians for direct therapy, would you prefer:

          HIPPA Acknowledgement

          Patient Name(Required)
          Clear Signature
          Please complete this section if the patient is unable to sign.
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