Intake Form Client Intake Form Please complete the form below. Once submitted someone will reach out to you shortly. I. Client Information: Client's First Name Client's Last Name Client's Birth Date Client's Gender Female Male Non-Binary Other Prefer not to state Other (Please specify) Client's Ethnicity Alaska Native or Native American Asian or Asian American Black or African American Hispanic or Latino/Latina Middle Eastern or Arab Native Hawaiian or Pacific Islander White or Caucasian Other Other (Please specify) Client's Language Spoken (Primary) English Spanish Chinese French Hebrew Russian Other Client's Language Spoken (Secondary) N/A English Spanish Chinese French Hebrew Russian Other Client's Address Client's City Client's State Client's Zip Code School/Daycare Name (If Applicable) School/Daycare Address (If Applicable) School/Daycare Hours (If Applicable) II. Parent/Guardian Information Parent/Guardian First Name Parent/Guardian Last Name Parent/Guardian Street Address (If Different From Client) Parent/Guardian City Parent/Guardian State Parent/Guardian Zip Code Parent/Guardian Email Parent/Guardian Phone III. Insurance Information: Primary Insurance Insurance ID Name of policy holder/Insured Relationship to client Policy holder DOB Street Address of Policy Holder (If Different From Client) Policy Holder City Policy Holder State Policy Holder Zip Code Primary Insurance Card Primary Insurance Card Front Side Primary Insurance Card Back Side Secondary Insurance Card (if applicable) Secondary Insurance Card Front Side Secondary Insurance Card Back Side IV. General Information Reason for Referral Has client been diagnosed with Autism?* Yes No Who gave diagnosis? Date of diagnosis Hours available for ABA services Pediatrician name and phone number How did you hear about Thrive Therapy? Is there any other information that you would like to share? Please upload any documents we may need (jpg, jpeg, png, pdf, doc, docx files only) V. Emergency Contact Information: (Other than parent listed above) First Name Last Name Relationship to Client Phone VI. Acknowledgement Parent Signature Today's Date * By checking this box, you agree to be contacted by someone from the Thrive Therapy team Submit