Client Intake Form

Date*

Name*

Prefix

First

Last

Suffix

Age*

Date of Birth*

Diagnosing Physician*

Primary Diagnosis*

Other Diagnosis

Did Child Have: Check Appropriate Box(es)

Address*

Street Address

City

State

ZIP Code

County*

Home Phone*

Biomedical Treatment(s): (ie GFCF Diet)

Other Disabilities (ie visual or hearing impairments)

Primary Care Physician*

Primary Care Physician Phone*

Allergies or Medical Alerts

Current Medications/Supplements (list all, include dosage)

School Information

Does Your Child Attend School?

Yes
No

Name of School

School's Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

If Yes, How many Hours Per Week Does Your Child Attend School?

In What Type of Classroom Does Your Child Attend School?

Does your child receive other services? (Example: OT, PT, Speech, Etc.)

Please indicate number of hours per week for each type of service.

Parent/Guardian Information

Parent/Guardian #1 Name*

Prefix

First

Last

Suffix

Relationship to Client*

Home Phone*

Cell Phone

Address (If Different From Above)

Street Address

City

State

ZIP Code

Email

Fax

Marital Status

Married
Divorced
Separated
Single

Parent/Guardian #2 Name*

Prefix

First

Last

Suffix

Relationship to Client*

Home Phone*

Cell Phone

Address (If Different From Above)

Street Address

City

State

ZIP Code

Email

Fax

Insurance Information

Primary Insurance Provider*

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

Secondary Insurance Provider*

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

Insured Persons Name*

Insured Person's Work Address*

Street Address

City

State

ZIP Code

Insured Person's Date of Birth*

Client Behavior Information

Describe how your child communicates with others

Highly Preferred Activities/Items (favorite snacks, activities, toys/leisure items, characters, etc.)

Problem Behaviors

Check all the behaviors the client exhibits

Physical Aggression towards others: Check Appropriate Box(es)

Other Aggressive Behaviors

Frequency: (# times/day, # times/hr, Daily, Once/week, etc.)

Severity: Check Appropriate Box(es)

Mild
Moderate
Severe

What events seem to increase the likelihood the behavior will occur?

What do others do when the behavior occurs?

What is generally believed as the “cause” of this behavior for this person?

Self-Injurious Behaviors (assaults on own body): Check Appropriate Box(es)

Head-banging
Biting
Hitting
Scratching/Picking Skin

Other Self-Injurious Behaviors

Frequency: (# times/day, # times/hr, Daily, Once/week, etc.)

Severity: Check Appropriate Box(es)

Mild
Moderate
Severe

What events seem to increase the likelihood the behavior will occur?

What do you or others do when the behavior occurs?

What is generally believed as the “cause” of this behavior for this person?

Self-Stimulation Behaviors: Check Appropriate Box(es):

Hand-flapping
Body Rocking
Spinning Body
Spinning Items

Other Self-Stimulation Behaviors

Frequency: (# times/day, # times/hr, Daily, Once/week, etc.)

Severity: Check Appropriate Box(es):

Mild
Moderate
Severe

What events seem to increase the likelihood the behavior will occur?

What do you or others do when the behavior occurs?

What is generally believed as the “cause” of this behavior for this person?

Other Problem Behaviors: Check Appropriate Box(es):

Self-induced vomiting
Elopement (running away)
Tantrums
Property Destruction

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.

I've read the above and agree*

Yes
No

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've read the above and agree*

Yes
No

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.

Check Appropriate Box:*

Yes
No

Parent/Guardian Signature- We will need a signed copy for our files.*

Comments

This field is for validation purposes and should be left unchanged.

Heart To Heart For Autism

Patient Information

School Information

Parent/Guardian Information

Insurance Information

Client Behavior Information

Problem Behaviors

Liability Waiver

Financial Waiver