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ABA Intake Form
Admin
September 12, 2022
September 12, 2022
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Step
1
of 7
Child/Patient Information
Full Name
*
First
Last
Date Of Birth
*
Soc. Sec. #
*
Address
Address Line 1
City
State / Province / Region
Email
*
Phone Number
*
School Attending
Are there siblings living in the home?
Yes
No
If yes, how many?
Who else lives in the home?
Next
Parent/Legal Guardian Information
Name of Parent 1
First
Last
Address
Address Line 1
City
State / Province / Region
Date Of Birth
Relationship to client
Occupation
Phone Number
Email
Name of Parent 2
First
Last
Address (Parent 2)
Address Line 1
City
State / Province / Region
Date Of Birth (Parent 2)
Relationship to client (Parent 2)
Occupation (Parent 2)
Phone Number (Parent 2)
Email (Parent 2)
What language are spoken at home
Previous
Next
Medical History/Treatment and Behavioral Information
Diagnosis
Name of Diagnosing Doctor
First
Last
Date of Diagnosis
Name of Physician/Pediatrician
First
Last
What other services is your child currently receiving both in school and out of school? (Complete chart below) Please email, fax, or mail a copy of the child’s most recent IEP or IFS
What past therapies or treatments have you done for/with your child (e.g. speech, OT, psychiatry)? Please explain below
Schedule (School or other therapies)
Medications: (Please list names, dosage, and what they are used for)
Any known allergies:
Are there any medical conditions that need to be considered when delivering ABA treatment? If yes, please explain below
Family History: Provide any relevant medical health family history information
What, if any, behavior issues does your child have? Ex., self-injurious, aggressive towards others, etc., please explain. Include methods used to decrease these behaviors. Please describe any suicidal risks or risks to harm others, if applicable
Psychosocial History (For children and adolescents: include pre-natal and post-natal events and developmental history. For teenagers and older: include history of sexual behavior and/or use of cigarettes, alcohol or other substances, if applicable):
Are you concerned about feeding, sleeping, or sensory/regulatory?
Yes
No
Are you concerned about your child’s thinking, memory, problem-solving, or curiosity?
Yes
No
Are you concerned about your child’s interaction and behavior?
Yes
No
What current communication skills does your child have? Ex., sign language, PECS, verbal, please explain below.
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Next
Goals and Commitment
What are your immediate goals for your child? Please explain below:
What level of commitment are you willing to make at home in order for your child to achieve the goals above?
Do you understand the risks of non-compliance with treatment recommendations?
Are there any relevant legal issues for your family?
Yes
No
if yes, please explain
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Next
Authorization to Process and Appeal Claims
I do hereby authorize:
(Please fill Parent/Guardian Name)
Oaks Dynamics Inc, including all employees, to RELEASE TO and OBTAIN FROM information from the record of:
(Please fill Child/Client Name and Date of Birth)
Oaks Dynamics Inc. including all employees, to process and appeal claims for services they render for:
(Please fill Child/Client Name and Date of Birth)
through my/his/herinsurance
(Please fill Insurance Policy Name and ID #)
I also authorize Oaks Dynamics Inc. to communicate with:
(Please fill Insurance Company)
regarding all medical and financial information contained in my insurance file. I understand this information is confidential and will only be released as specified in this authorization.
(Signature of Parent/Guardian and Date)
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Next
Assignment of Benefits
I do hereby assign all Healthcare benefits, to include major medical benefits
(Please fill Parent/GuardianName)
to which I/my child is entitled. I hereby authorize and direct my insurance carrier to issue payment check(s) directly to Oaks Dynamics Inc. for self and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.
(Please fill Child/Client Name)
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Next
Informed Consent to Treatment and Assessment
I will be given a clear description from my/my child’s behavioral health provider regarding the problems, diagnosis, personal strengths/limitations and treatment interventions proposed.
I understand that my/my child’s behavioral health provider cannot guarantee results of behavioral health services. However, there will be clearly stated reasons, goals, and objectives for continuing/discontinuing behavioral health treatment. I understand the risks of noncompliance with treatment. This will be discussed with my/my child’s behavioral health provider.
I understand that I have the right to an interpreter (sign or language) if necessary. I understand that if I have a grievance with my/my child’s behavioral health provider, I will first attempt to communicate this directly to him/her. In the event that the grievance is not satisfactorily resolved, I understand how to complete a “Feedback Form”.
I understand that this “Informed Consent/Limits of Confidentiality Form” is not intended to be “all inclusive” of aspects of my/my child’s behavioral health treatment. It is only intended to provide some useful information before deciding to engage in behavioral health treatment.
I will be given a clear recommendation for the types of treatment recommended, such as Applied Behavioral Analysis (ABA) or parent training. Times, dates, and session length will be discussed with my behavioral health provider.
I voluntarily agree to undergo behavioral health treatment and understand that I may end treatment at any time for me/my child. I understand that my behavioral health provider may want to discuss this with me/my child, but that I reserve the right to stop treatment. Furthermore, I understand that my/my child’s behavioral health provider may make diagnostic and treatment recommendations with which I do not agree (e.g. modality of treatment, duration of treatment, frequency of visits, etc.).
Limits of Confidentiality
The information that you/your child shares with your Behavioral Health Provider is considered to be confidential. In most cases, information cannot be released to another party without your written consent. However, in certain circumstances, information can be shared legally without your permission.
These circumstances include:
1. Suicide: if you/your child are assessed to be a danger to yourself; cannot guarantee your physical safety against the intention of suicide; and/or have immediate suicidal plans, this information is not considered to be “confidential”. Actions may be taken to ensure your safety.
2. Homicide: if you are assessed to be a danger to others; cannot guarantee their safety; and have immediate, specific plans to cause fatal injury/harm to another person, this information is not considered to be “confidential”. Actions may be taken to protect the safety of others. The police may be notified of your intentions as well as the intended victim.
3. Court order/subpoena: Your Behavioral Health Provider(s) can be required to relinquish a copy of your written Behavioral Health Record to the appropriate Courts. Behavioral Health Providers can also be subpoenaed to testify in court without your consent.
4. Child abuse/neglect: Maryland Law requires your Behavioral Health Provider to report to the appropriate authorities (i.e. Child Protective Services) any suspicion or evidence of child abuse or neglect. This law also applies to past incidents of abuse or neglect.
5. Elder abuse/neglect: Maryland Law requires your Behavioral Health Provider to report to the appropriate authorities any suspicion or evidence of elder abuse/neglect.
6. Laws regarding minors in behavioral health services: certain information may be shared with parent/legal guardians at the discretion of the behavioral health provider(s).
B. Behavioral Health confidential information may also be used in a number of ways within Oaks Dynamics Inc. without your written permission for coordinating services and delivering quality care. You may be informed if this is the case.
These may include:
a. Consultations and case conference with other providers at Oaks Dynamics Inc.
b. In supervisory meetings with student interns at Oaks Dynamics Inc.
c. With providers in other services here at Oaks Dynamics Inc.
d. For billing purposes: a diagnosis is given to your insurer for reimbursement purposes.
By signing below, you are indicating that you have read and understand the contents above, that you’ve had an opportunity to ask questions, that they have answered to your satisfaction, and that you agree to the services outlined.
*
Clear Signature
Signature and Date.
Full Name
*
First
Last
For: Parent/Guardian/Substitute Decision Maker
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