Intake Form | Growing Minds

Growing Minds ABA Therapy Center, NFP

Client Intake Packet and Referral Partnership Forms

This intake packet is designed to collect essential information needed to evaluate, admit, and provide Applied Behavior Analysis (ABA) services to clients at Growing Minds ABA Therapy Center, NFP. All information provided is confidential and protected under HIPAA regulations.

SECTION 1: CLIENT INTAKE APPLICATION

Client Full Name

Date of Birth

Month

Day

Year

Age

Gender

Home Address

City

State

Zip Code

Primary Language Spoken at Home

Parent/Guardian Name(s)

Primary Phone Number

Secondary Phone Number

Email Address

Preferred Method of Communication

Does the client have an Autism diagnosis?

Yes

If yes, diagnosing provider and date of diagnosis

School Currently Attending (if applicable)

Current Services (speech therapy, occupational therapy, etc.)

Growing Minds ABA Therapy Center, NFP

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