Intake Form

Client Intake Form

Please complete the form below. Once submitted someone will reach out to you shortly.

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

I. Client Information:

First Name

Last Name

Date of Birth

Parent Name

First Name

Last Name

Address

City

State

Zip Code

Gender

Phone

Reason for Referral

School/Daycare (if applicable)

Address of school/daycare

School/daycare hours

Has client been diagnosed with Autism?*

Yes No

Who gave diagnosis?

Date of diagnosis

Pediatrician name and phone number

Hours available for ABA services

II. Insurance Information:

Primary Insurance

Insurance ID

Name of policy holder/Insured

Relationship to client

Policy holder DOB

Address (if different from client home)

Address Line 1

Address Line 2

Postal Code

City

Country

III. Emergency Contact Information: (Other than parent listed above)

First Name

Last Name

Relationship to Client

Phone

IV. Parent Signature

Parent Signature

Today's Date

By checking this box, you agree to be contacted by someone from the Thrive Therapy team

Is there any other information that you would like to share?

Who referred you to Thrive?

Does your child have a Written Order for ABA therapy?

Yes No

Please upload any documents we may need for your child