Client Intake Modal

Heart & Home ABA Client Intake

Complete the intake packet so our team can verify benefits, collect required consents, provision the client folder, generate the PDF packet, and prepare for assessment and care planning.

Client Intake Form

Complete all required fields (*). Upload fields are placed next to the related question.

Client / Child Information

Client Full Name * Date of Birth *

Social Security Number (SSN) * Gender *

Diagnosis * Upload Diagnosis Report *

Address

Street Address *Apt / Unit #

City *State *ZIP *

Primary Parent / Guardian

Full Name *Relationship to Child *

Email *Phone Number *

Parent/Guardian Photo ID — Front *Parent/Guardian Photo ID — Back *

Secondary Parent / Guardian

Full NameRelationship to Child

EmailPhone Number

Secondary Parent/Guardian Photo ID — FrontSecondary Parent/Guardian Photo ID — Back

Primary Insurance Information

Insurance Company *Member / Policy Number *

Group NumberPolicy Holder Name *

Primary Insurance Card — Front *Primary Insurance Card — Back *

Secondary Insurance (if applicable)

Insurance CompanyMember / Policy Number

Group NumberPolicy Holder Name

Secondary Insurance Card — FrontSecondary Insurance Card — Back

Referral & Physician

Referred ByReferral Source Type

Primary Care PhysicianPhysician Phone

Upload Referral or Prescription (if available)

Emergency Contact

Full Name *Relationship *

Phone Number *Alternate Phone

Scheduling Preferences

Preferred daysPreferred timesEarliest start date

Location preferenceScheduling notes

Current Services (optional)

Check all that apply and add weekly hours where known.

Speech Therapy Occupational Therapy Physical Therapy ABA (with another provider)

ABA hours/weekOT hours/weekST hours/week

Helpful for medical necessity: include provider name, total hours/week, start–end dates, outcomes, and reason for discharge.Other (optional)

Communication & Learning

Primary communication modeTypical utterance length (MLU)Listener skills

Top requests (mands)Replacement communication already taught

Social & Play

Play stagePeer interaction barriers

Restricted interests (duration; interference with learning?)

Priority Behaviors (Top 3)

For each behavior, describe what it looks like, how often it occurs, average duration, intensity (1–5), known triggers/setting events, and what helps.

Behavior 1

Topography *Operational definition

FrequencyAvg duration (min)Intensity (1–5)

Known antecedents / setting eventsLikely function

What helps (effective strategies tried)

Behavior 2

Topography Operational definition

FrequencyAvg duration (min)Intensity (1–5)

Known antecedents / setting eventsLikely function

What helps

Behavior 3

Topography Operational definition

FrequencyAvg duration (min)Intensity (1–5)

Known antecedents / setting eventsLikely function

What helps

Safety Risk & Crisis Planning

Elopement — last incident dateElopement details (distance/locations)Access to roads/water bodies

SIB — body sitesProtective equipment used?Aggression/Property Destruction injury history

Weapons/sharp objects access; locking protocolCrisis plan in place? Who is trained?

Daily Living (Adaptive)

Toileting statusFeeding notes (safe foods, texture tolerance)Sleep pattern

Hygiene/dressing independenceCommunity skills

Medical & Sensory

Co-occurring conditions (ADHD, anxiety, epilepsy, GI)Medications & timesAllergies

Vision/hearing status; most recent evalsSensory profilePain indicators & how expressed

Environment & Routines

Home environment notesRoutines & transitionsPreferred ABA session length & weekly tolerance

Motivation & Reinforcement

High-preference items/activitiesEO/MO notes (satiety, competing reinforcers)

Education & Collaboration

School / Daycare

Current placementSchool team contactsCollaboration preference

IEP/504 Plan

Does the client have an IEP or 504 Plan? *Upload IEP/504 Plan Document (if available)

Caregiver Training & Generalization

Top 3 caregiver goalsTraining comfort & format

Generalization settings (real-life targets)

Additional Notes

Consent for ABA Treatment

By checking the box below, I confirm that I am the parent or legal guardian of the child identified in this form and I give permission for Heart & Home ABA, LLC to provide Applied Behavior Analysis (ABA) services to my child, including assessment, direct treatment, clinical supervision, and caregiver training as clinically indicated. I understand that participation is voluntary and that I may withdraw this consent at any time by notifying Heart & Home ABA, LLC in writing.

I consent to ABA treatment for my child *

Assignment of Benefits

By checking the box below, I authorize my health insurance plan(s) to pay benefits for covered services directly to Heart & Home ABA, LLC. I understand that this assignment of benefits allows Heart & Home ABA, LLC to bill and receive payment from my insurer on my behalf. I agree to promptly forward to Heart & Home ABA, LLC any payment I receive for services they provided to my child, and I understand that this assignment does not relieve me of responsibility for charges not paid by insurance.

I authorize direct payment of insurance benefits *

Client & Caregiver Responsibilities: Safe, Therapeutic Environment

By checking the box below, I confirm that I have received access to, read, and understand the Client & Caregiver Responsibilities: Maintaining a Safe, Therapeutic Environment Policy for Heart & Home ABA, LLC (linked below). I understand that this policy describes my obligations to maintain a safe, clean, and respectful environment during sessions, and I agree to follow these expectations and to contact the office and my child’s BCBA promptly if any safety or environment barriers arise. I understand that failure to maintain a safe, therapeutic environment may affect scheduling or continuation of services.

View Client & Caregiver Responsibilities Policy (PDF)

I agree to follow the Client & Caregiver Responsibilities policy *

Client Attendance & Sick Policy

By checking the box below, I confirm that I have received access to, read, and understand the Client Attendance & Sick Policy for Heart & Home ABA, LLC (linked below). I understand that consistent, year-round attendance and following the sick policy are required for my child to receive and continue ABA services, and that excessive cancellations, no-shows, or failure to follow the sick guidelines may result in schedule changes, temporary holds, or discharge from services. I agree to follow this policy and to communicate with the office and my child’s BCBA if barriers arise.

View Client Attendance & Sick Policy (PDF)

I agree to follow the Client Attendance & Sick Policy *

Financial Responsibility

By checking the box below, I agree that I am financially responsible for all charges for services provided by Heart & Home ABA, LLC that are not paid in full by my insurance, including co-pays, co-insurance, deductibles, non-covered services, and amounts denied by my plan. I agree to pay balances when due, to inform Heart & Home ABA promptly of any insurance changes, and I understand that unpaid balances may lead to collection activity or an interruption of services.

I accept financial responsibility *

HIPAA Acknowledgment

By checking the box below, I acknowledge that Heart & Home ABA, LLC has made its Notice of Privacy Practices available to me as required by the Health Insurance Portability and Accountability Act (HIPAA). I understand that this Notice explains how my child’s protected health information may be used and disclosed, how I can access and request amendments to that information, and how I may file a privacy complaint if needed.

Notice of Privacy Practices

I acknowledge receipt of the Notice of Privacy Practices *

School Collaboration Consent

By checking the box below, I authorize Heart & Home ABA, LLC to exchange relevant information about my child’s educational and behavioral needs with my child’s school or educational team (such as teachers, case managers, school psychologists, and related service providers) for the purposes of coordinating goals, sharing progress, and supporting my child’s education. I understand that this authorization is voluntary and that I may revoke it in writing at any time, except to the extent that information has already been shared in reliance on this consent.

I authorize school collaboration *

Release of Information Authorization

By checking the box below, I authorize Heart & Home ABA, LLC to obtain and share relevant information about my child with other healthcare providers, mental health professionals, school personnel, and my insurance company as reasonably needed for treatment, care coordination, utilization review, and billing. I understand that this authorization is voluntary, that I may revoke it in writing at any time (except for information already used or disclosed), and that it will otherwise remain in effect until one (1) year after my child is discharged from services with Heart & Home ABA, LLC.

I authorize release of information *

Telehealth Consent

By checking the box below, I consent to Heart & Home ABA, LLC providing ABA services to my child through telehealth (audio and/or video communication) when clinically appropriate. I understand that telehealth may differ from in-person services, that there are potential risks such as technical failures or limits to privacy in my home environment, and that I am responsible for creating as private a space as possible during sessions. I understand that I may withdraw this consent at any time by notifying the office in writing, which may affect how services can be provided.

I consent to telehealth services *

Photo & Video Recording

Recordings may be used only for treatment planning, supervision, and staff training, and are kept confidential. No marketing use without additional written permission.

Photo/Video Recording Preference * By selecting this option, I consent to photo and/or video recording of my child by Heart & Home ABA, LLC for treatment planning, data collection, clinical supervision, and staff training only. I understand that these recordings will be kept confidential and will not be used for marketing or public purposes without my separate written permission. By selecting this option, I do not consent to photo or video recording of my child by Heart & Home ABA, LLC for any purpose, unless I provide separate written permission at a later date. I understand that this choice will not affect my child’s eligibility to receive services.

Consent to Electronic Records & Signatures

By checking this box, I agree to the use of electronic records and electronic signatures with Heart & Home ABA, LLC instead of paper documents. I understand that my electronic signature has the same legal effect as a handwritten signature under applicable law, and that I may request paper copies of records or forms at any time.

I consent to electronic records and signatures *

SMS Text Message Communications

Heart & Home ABA may use SMS text messaging for appointments, scheduling, intake updates, support requests, service notifications, account updates, and other administrative communications.

By providing my mobile phone number and checking this box, I consent to receive SMS text messages from Heart & Home ABA regarding appointments, scheduling, intake updates, support requests, service notifications, account updates, and other administrative communications. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out and HELP for assistance. *

Signature & Acknowledgment

By signing below, I confirm that I am the parent or legal guardian of the client identified in this intake, that I have reviewed the intake information and all consents and acknowledgments listed above, and that I agree to the terms and expectations described.

Parent / Guardian Signature (Type Full Name) *Date Signed *

Draw Signature (mouse or touch) *

Your drawn signature will be securely submitted with this form.