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ABA Therapy Intake Form
Please fill out this form to help us understand your needs and preferences for ABA therapy.
Do you have a current autism diagnosis?
*
Yes
No
In progress
Need to get evaluated
Parent/Guardian Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Full Name
*
First Name
Middle Name
Last Name
Client's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client's Gender
*
Male
Female
Non-binary
Prefer not to say
Do both parents/guardians support exploring ABA therapy services?
*
Yes
No, but I have full custody of my child and will share the documentation to prove it.
What is your preferred location?
*
Clearfield
Lindon
Midvale
Riverton
Saratoga Springs
West Jordan
In-Home
What hours are you interested in?
*
Clinic: 9am-12pm - Monday-Friday (Ages 2-7)
Clinic: 12pm-3pm - Monday-Friday (Ages 2-7)
Clinic: 9am-3pm - Monday-Friday (Ages 2-7)
Clinic: 3:30pm - 5:30pm - 3-5 days a week (Ages 7-12)
In-Home: 9am-11:30am - Monday-Friday (All Ages)
In Home: 12:30pm-3pm - Monday-Friday (All Ages)
In Home: 3:30pm-5:30pm - 3-5 days a week (All Ages)
Please describe any scheduling conflicts you may have including naps, school schedule, or other therapy.
*
Please provide us with your current concerns and indicate the specific assistance you require.
*
Has your child received ABA therapy before?
*
Yes
No
Currently receiving ABA
If you child has received ABA before, or is currently receivig ABA, what prompted the transition from your current/previous provider?
*
Preferred method of contact.
*
Phone Call
Text
Email
Affinity Autism Services accepts most major insurances. Pleast select your primary insurance provider.
*
Please Select
Aetna
Blue Cross Blue Shield
Medicaid
Molina Healthcare
United Healthcare
University Of Utah
Anthem (Blue Cross Blue Shield)
Regence (Blue Cross Blue Shield)
Select Health
MotivHealth
PEHP Health & Benefits
Cigna
DMBA
EMI Health
ChampVa
ComPsych
Insurance Policy Holder's Full Name
*
First Name
Last Name
Insurance Policy Holder's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How did you hear about us?
*
Referral from a Professional
Family or Friend
Current Client
Online Search
Social Media
Market or Event
Other
Please upload ALL Insurance Cards: FRONT & BACK
*
Browse Files
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Accepted File types: pdf, jpg,png
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Please upload the complete ASD Evaluation
*
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Valid Evaluation should include: Clinician's Signature (MD,PhD,Psychologist) Standardized tests used with scores. Official diagnosis F84.0. ABA is explicitly recommended.
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*
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