Client Intake Packet

Playful Minds ABA – Client Intake Packet

Child Information

Child's Full Name:

Date of Birth:

Gender:

Address:

Primary Language:

Secondary Language:

Parent/Guardian Information

Parent/Guardian #1 Name:

Relationship to Child:

Phone Number:

Email:

Address (if different):

Parent/Guardian #2 Name:

Relationship to Child:

Phone Number:

Email:

Insurance Information

Primary Insurance Provider:

Member ID:

Group #:

Insurance Phone #:

Policy Holder Name:

Policy Holder DOB:

Relationship to Child:

Diagnosis & Medical Information

Primary Diagnosis:

Date of Diagnosis:

Diagnosing Provider/Facility:

Other Medical Conditions:

Allergies:

Current Medications:

Primary Care Physician:

Physician Phone #:

Educational Information

Current School:

School District:

Grade:

IEP or 504 Plan:

ABA Services Requested

Additional Service Details

Preferred Days/Times:

How did you hear about us:

Behavioral & Developmental Information

Communication Style:

Challenging Behaviors:

Skill Areas of Concern:

Reinforcement & Preferences

Favorite activities:

Favorite toys:

Preferred snacks/foods:

Sensory preferences or triggers:

HIPAA Notice of Privacy Practices

Playful Minds ABA is committed to protecting your child's health information. Uses and Disclosures Permitted:

Treatment – sharing information with providers.

Payment – billing insurance.

Healthcare Operations – quality improvement, training.

Consent for ABA Treatment

AI authorize Playful Minds ABA to provide Applied Behavior Analysis (ABA) services to my child.

Parent/Guardian Consent:

Date

Month

Day

Year

Client Intake Packet

Playful Minds ABA – Client Intake Packet

Child Information

Parent/Guardian Information

Insurance Information

Diagnosis & Medical Information

Educational Information

ABA Services Requested

Additional Service Details

Behavioral & Developmental Information

Reinforcement & Preferences

HIPAA Notice of Privacy Practices

Consent for ABA Treatment

Providing ABA services throughout the Metroplex!