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 / Child Information

Client Full Name *Date of Birth *Social Security Number *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 / GuardianExpand

Full Name Relationship to Child Email Phone Number Secondary Parent/Guardian Photo ID — Front Secondary Parent/Guardian Photo ID — Back

Primary Insurance Information

Insurance Company *Member / Policy Number *Group Number Policy Holder Name *Primary Insurance Card — Front *Primary Insurance Card — Back *

Secondary InsuranceExpand

Complete if applicable.

Insurance Company Member / Policy Number Group Number Policy Holder Name Secondary Insurance Card — Front Secondary Insurance Card — Back

Referral & PhysicianExpand

Referred By Referral Source Type Primary Care Physician Physician Phone Upload Referral or Prescription

Emergency Contact

Full Name *Relationship *Phone Number *Alternate Phone

Priority Behaviors — Top 3Expand

For each behavior, describe what it looks like, frequency, duration, intensity, triggers, likely function, and what helps.

Behavior 1 Topography *Behavior 1 Operational Definition *Behavior 1 Frequency *Behavior 1 Avg Duration (min) Behavior 1 Intensity (1–5) *Behavior 1 Known Antecedents / Setting Events Behavior 1 Likely Function Behavior 1 What Helps Behavior 2 Topography Behavior 2 Operational Definition Behavior 2 Frequency Behavior 2 Avg Duration (min) Behavior 2 Intensity (1–5) Behavior 2 Known Antecedents / Setting Events Behavior 2 Likely Function Behavior 2 What Helps Behavior 3 Topography Behavior 3 Operational Definition Behavior 3 Frequency Behavior 3 Avg Duration (min) Behavior 3 Intensity (1–5) Behavior 3 Known Antecedents / Setting Events Behavior 3 Likely Function Behavior 3 What Helps

School / Daycare Service LocationExpand

If the client attends school or daycare, add the actual service location and a location contact. This information is used for scheduling, travel, cancellations, and service-change notifications.

School / Daycare NameSchool Placement

Service Location Address

Start typing and select the correct Google Maps result so the street, city, state, ZIP, and map coordinates are saved with the client.

Find School / Daycare Address with Google Maps

Start typing and select a Google Maps result. Street, city, state, and ZIP will fill automatically; you can still edit them manually.

Address Line 1Address Line 2CityStateZIP

Location Contact NameLocation Contact EmailLocation Contact PhoneSchool Team ContactsCollaboration Preference

Communication & LearningExpand

Primary Communication Mode Mean Length of Utterance (MLU) Listener / Receptive Skills Top Requests / Wants Replacement Communication Goals

Social & PlayExpand

Play Stage Peer Interaction Barriers Restricted / Preferred Interests

Daily Living (Adaptive Skills)Expand

Toileting Feeding Sleep Hygiene / Dressing Community Skills

Medical & SensoryExpand

Co-occurring Conditions Current Medications Allergies Vision / Hearing Concerns Sensory Profile Pain Indicators

Safety Risk & Crisis PlanningExpand

Last Elopement Date Protective Equipment Used Elopement Details Hazard Access (water, roads, etc.) Self-Injury Sites / Locations Injury History Weapons / Sharps Access Concerns Existing Crisis Plan

Current ServicesExpand

Speech TherapyOccupational TherapyPhysical TherapyABA (Other Provider)ABA Hours / Week OT Hours / Week ST Hours / Week Other Services

Environment & CaregiverExpand

Home Environment Notes Daily Routines Session Tolerance High-Preference Reinforcers Establishing / Motivating Operations Notes Education Plan Upload IEP / 504 Plan (optional) Caregiver Training Goals Preferred Training Format Generalization Settings

Signature

Typed Signature (Full Legal Name) *Date *

Drawn Signature *

Draw your signature above using your mouse or finger.