Nice to Meet You! Please submit the form below to get started. Client Information * First Name Last Name * Date of Birth MM DD YYYY * Gender Male Female Other Diagnosis (if applicable) Primary Language English Spanish Other Does the client use assistive communication devices? Yes No Parent/Guardian Information (If applicable) First Name Last Name Relationship to Client Mother Father Other * Phone (###) ### #### * Email Address Address 1 Address 2 City State/Province Zip/Postal Code Country Insurance Information Insurance Provider Policy Holder First Name Last Name Member ID Group # Is the client currently receiving other therapy services? Speech OT PT Counseling Other Please provide provider names and contact information if applicable: Services Requested * What behaviors or skills are you seeking support for? Are there specific goals you would like ABA to address? Communication Social Skills Daily Living Emotional Regulation School Readiness Reducing Challenging Behavior Other Preferred Setting for ABA Services * Please check all that apply: In-home Clinic-based School-based Community-based Telehealth (if appropriate) Other Preferred Session Time * Weekday AM Weekday PM Weekends Current Behaviors of Concern * Please check all that apply and provide details: Tantrums/Meltdowns Aggression (e.g., hitting, biting, kicking) Self-Injurious behavior (e.g., head banging, biting self) Elopement (running away from supervision) Property Destruction Noncompliance Disrobing Inattention/Hyperactivity Repetitive behaviors/Stimming Excessive crying/screaming Inappropriate language or vocalization Food refusal or feeding issues Toileting difficulties Sleep issues Other * Please describe any behaviors checked above (e.g., triggers, frequency, duration, context): Client Educational Background * School/Program Currently Attending * Grade Level/Program * IEP or 504 Plan in Place? Yes No Additional Notes or Concerns Signature & Consent * By stating my name below, I certify that the information provided is accurate to the best of my knowledge and I authorize Greater Atlanta Behavioral Clinic to contact me regarding ABA therapy services. First Name Last Name Thank you!
