New Client Intake Survey
Client / Child's Name
*
Client's Address
*
Client Date of Birth
*
City
*
Zip Code
Parent/Caregiver First Name
*
Parent/Caregiver Last Name
*
Address (if different from client)
Email
*
Phone
*
Name of Policy Holder:
Insurance Carrier
Aetna
Highmark BCBS
UPmc Health Plan
Optum
Cigna
Unsure
Other
Uninsured
No elements found. Consider changing the search query.
List is empty.
Insuracne Carrier (if Other)
Insurance ID #:
Group #:
Has your child been diagnosed with Autism Spectrum Disorder within the past 3 years?
Yes
No
Assessment Scheduled
Where can my child be assessed?
No elements found. Consider changing the search query.
List is empty.
Has your child received ABA within the last 6 months
Yes
No
No elements found. Consider changing the search query.
List is empty.
How did you hear about us?
When are you looking to start in our therapy program?