Client Intake Form

NOTE: This form only needs to be submitted once per client. If you’ve already submitted one, you do not need to resubmit.

Patient Information
































  • School Information





















  • Please indicate number of hours per week for each type of service.
  • Parent/Guardian Information

























































  • Insurance Information

  • *We also need a copy of Insurance Card front and back
  • *We also need a copy of Insurance Card front and back












  • Client Behavior Information

  • Problem Behaviors

    Check all the behaviors the client exhibits






































  • List Day of Week Followed By Start Time and End Time (Example: Monday 4pm – 6pm)
  • Liability Waiver

    In consideration of (“my child’s or children’s”) participating in activities at Heart to Heart & Associates LLC, I agree to assume all risk and hereby waive, and release Heart to Heart & Associates LLC and its officers, directors, employees and instructors from any and all claims or causes of action for injury, damage or loss to the person or property of my child. I further agree to indemnify and hold Heart to Heart & Associates LLC harmless from any and all losses, claims or causes of action for injury, damage or loss in any way relating to or arising from any incidents occurring at its facility. This waiver and release is intended to be an express waiver and release from any and all claims against Heart to Heart & Associates LLC arising from my child’s participation in any activities, including all claims or causes of action based upon the alleged negligence or gross negligence of Heart to Heart & Associates LLC. This agreement shall remain in effect as long as and whenever my child participates in activities at Heart to Heart & Associates LLC. I also grant Heart to Heart & Associates LLC permission to provide emergency assistance and obtain medical care in the event of a medical emergency.
  • Financial Waiver

    I acknowledge that I have been informed in advance that I am ultimately financially responsible for all services are not covered by my health insurance plan. By signing this financial waiver, I am hereby agreeing in advance, in writing, to accept full financial responsibility for all costs associated with services provided by Heart to Heart & Associates LLC.
  • I give Heart & Associates LLC the right to use and copyright photographs of my child taken at Heart to Heart & Associates LLC (but not his or her name) in Heart to Heart & Associates LLC print and electronic advertisements.
  • This field is for validation purposes and should be left unchanged.


Please Include
1. FULL REPORT FROM DIAGNOSING PHYSICIAN (DEVELOPMENTAL PEDIATRICIAN OR PEDIATRIC NEUROLOGIST) EITHER ORIGINAL OR MOST CURRENT. MUST HAVE DIAGNOSIS ON DOCUMENT WITH PHYSICIAN’S NAME.
2. PRESCRIPTION FOR ABA THERAPY.
3. PLEASE PROVIDE US A COPY OF INSURANCE CARD FRONT AND BACK