Intake Form – Sprout & Bloom ABA Therapy

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Child's Name

First

Middle

Last

Child's Date of Birth

Parent/Guardian Name

Parent/Guardian Email

Parent/Guardian Phone Number

Address

Address Line 1

City

State

Zip Code

Insurance Provider:

Insurance Policy Number:

Insurance Group Number:

Insurance Primary Subscriber Full Name:

Insurance Primary Subscriber Phone Number:

Insurance Primary Subscriber DoB:

Upload a copy of the FRONT of the insurance card.

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Upload a copy of the BACK of the insurance card.

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Primary Care Physician Name/Phone Number:

Does your child have a formal diagnosis?

Is there a referral for ABA therapy?

If yes, please provide the date of diagnosis

If yes, please provide the name of the referral physician:

Medical Conditions/Diagnoses:

Allergies

Medications (Name, Dosage, Frequency) and Dietary Restrictions:

have Frequency) Plan

Emergency Contact Name

Emergency Contact Phone Number

Pregnancy and Birth History (complications, full-term, premature, etc.):

Milestones (age at which the child started walking, talking, etc.):

Previous Assessments/Evaluations (provide dates and results):

Previous Therapies/Interventions (e.g., speech therapy, occupational therapy):

Current Therapies (frequency and type):

Describe Behaviors of Concern:

Triggers for Behaviors (specific situations, times, places):

Frequency and Duration of Behaviors:

Strategies Used at Home to Manage Behaviors:

Current School/Program: Grade: Teacher's Name: IEP/504 Plan in Place (Yes/No): If yes, please provide a copy.

Child's Strengths and Interests:

If Yes above, kindly provide a copy of your child's IEP/504 Plan

Click or drag a file to this area to upload.

Social Interactions (with peers, adults):

Child’s Primary Mode of Communication (verbal, non-verbal, assistive device):

Family Information - Names and Ages of Siblings: Family’s Cultural or Religious Considerations: Involvement in Community Activities (church, sports, clubs):

Preferred Activities and Play Interests: Challenges in Social Settings:

Goals and Expectations Goals and Expectations

Short-term Goals for ABA Therapy:
Long-term Goals for ABA Therapy:
Parent/Guardian Expectations from ABA Services:

Our office is open from 8am to 5pm. Parents have the option to participate in early drop-off or late pick-up. Are you interested in utilizing our extended care options? We offer early drop-off at 7am for $175 monthly and late pick-up at 6pm for $150 monthly. Please indicate if you would like to take advantage of these services.

Yes
No
Undecided

Please upload your medical diagnosis to ensure we have all the necessary information to conduct a thorough assessment and create an effective therapy plan for your child.

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Please upload any relevant documents, such as referrals etc.

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Is there any other information you would like to share with us?

Sprout and Bloom ABA Therapy Intake Form

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