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

Other (Please specify)

Client's Ethnicity

Other (Please specify)

Client's Language Spoken (Primary)

Client's Language Spoken (Secondary)

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