Client ABA Application

Date of Client Application

Days since Client Application

Referring Physician

Child's First Name

Child's Last Name

Child's Date of Birth

Age

Male

Female

Child's Address

City

State

Zip Code

Autism Diagnosis

Yes

Diagnosing Physician

Age of Diagnosis

Date of Diagnosis

Other Diagnosis

ASD Diagnosis Paperwork

Parent/Guardian

Relationship to child

Parent/Guardian DOB

Cell Phone

Insurance Plan

Policy #

Group #

Insurance Rank

Insurance Phone Number(back of card)

Policy Holder First Name

Policy Holder Last Name

Policy Holder DOB

Address

City

State

Zip

Front of Insurance Card

Back of Insurance Card

Policy Holder Drivers License

Medical Information

Speech-Language Details:

School Status:

Behavioral Concerns:

Participation Willingness:

Are you willing to Ensure childs guaranteed attendance at multiple weekly ABA session totalling a minimum of 20 hours per week?

Yes

If no, please explain

Are you willing to atten parent training 1-2 times per month?

Yes

If no, please explain

Are you willing to implement the recommend treatment plan to the best of your ability while in the home environment?

Yes

If no, please explain

Are you willing to make environmental modification at home as recommend?

Yes

If no, please explain

Potential Barriers:

Autism Diagnosis Received

Doctor Refferal Received