PATIENT INTAKE FORM

Please fill out the following form to help us determine your next steps.

Child's Full Name

Child's Date of Birth * required

Child's Primary Health Insurance

Member ID Number:

Child's Secondary Health Insurance. Type "NONE" if there is not one. If there is please provide the Member ID below.

Member ID Number:

Parent/Guardian's Name

Phone

Street Address

City and State

Parent's Email Address

Does your child have Any Medical Conditions that they are being treated for by a physician (i.e. epilepsy)? Yes or No

Does your child currently receive ABA services in the home, school, or clinic? If yes, please note that most insurance plans do not allow a child to receive ABA services from two providers at the same time. Before services can begin with us, your child will need to be discharged from their current ABA provider or have a confirmed discharge date. * Required

Yes

Does the child need Speech and/or Occupational Therapy? *

Yes

Does your child attend Daycare/Preschool or Elemenatry School? * Required

Yes

Daycare, Preschool or Elementary School Name. Please include the times your child attends

Does the child have an ASD diagnosis? If so, do you have the ASD report? *

Yes, and I have the ASD report.

Yes, but I do not have the ASD report.

Do you require Translation Services? *

Yes

Do you have Religious Preference? *

Yes

I declare that the info I’ve provided is accurate & complete

We will be in contact SOON!

(404) 422-9190 Office
(866) 704-2179 Fax
info@serc4children.org

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