Contact Us | Get in Touch with Inclusive ABA for Quality Services

Home
About
- About
- Process
Services
Careers
Locations
- Nevada
- Nebraska
- Colorado
- Utah
- Iowa
- Ohio
Insurance
Blog

Home
About
- About
- Process
Services
Careers
Locations
- Nevada
- Nebraska
- Colorado
- Utah
- Iowa
- Ohio
Insurance
Blog

Intake Form

Contact Us

1. Please enter the patient's information:

Phone:

Email:

Date of Birth:

Gender:

Female

Male

Social Security #:

Street Address:

Apt./Unit #:

City:

State:

Zip Code:

Mobile Phone:

Home Phone:

Work Phone:

Email:

Preferred contact method:

Mobile Phone

Home Phone

Work Phone

Email

Preferred Language:

English

Spanish

Other

Race (Please check all that apply):

White

Black

Asian

American Indian/Native Alaskan

Native Hawaiian/Pacific Islander

Other

2. Emergency Contact Information.

Relationship:

Address:

Apt/Unit #:

Phone Number:

Alt Phone Number:

3. Please provide a doctors note dated within the last 12 months stating this patient has an Autism Diagnosis.

4. Diagnosing Doctor

5. Do you have Medical Insurance?

Yes

No

6. Primary Insurance

Member ID / Policy #

Group Number

Client Relationship to Insured

Self

Spouse

Child

Other

Insured Name

Insured Phone #

Insured Date of Birth

Insured Gender

Female

Male

Insured Street Address

Insured City

Insured State

Zip Code

Do you have Secondary Insurance?

Yes

No

7. Please attach a copy of the front & back of the patients insurance card.

8. Does your child have any known allergies?

Yes

No

9. If yes, please list any allergies:

10. Has your child been diagnosed with a psychiatric condition other than ASD?

Yes

No

11. If yes, what?

12. Have you received mental health service(s) in the past?

Yes

No

13. If yes, please list reason for treatment and dates & prior provider used:

Does your child have (or had) any of these concerns:

14. Does your child have (or had) any of these concerns: Difficulty falling or staying asleep

Yes

No

Sleeping too little or too much

Yes

No

Daily feeling of sadness that doesn’t go away

Yes

No

Panic/Anxiety attacks

Yes

No

Problems concentrating

Yes

No

Mood fluctuates up and down

Yes

No

Remembering upsetting things constantly

Yes

No

Upsetting thoughts I can’t get out of my head

Yes

No

Repetitive behaviors I can’t stop

Yes

No

Constant worrying

Yes

No

Disordered eating/purging

Yes

No

Sexual Abuse

Yes

No

Physical/Verbal Abuse

Yes

No

Feeling tired almost every day

Yes

No

Questions about sexual identity

Yes

No

Feelings of low self-worth

Yes

No

Risky behaviors

Yes

No

Difficulty controlling my temper

Yes

No

Difficulty maintaining a job

Yes

No

Difficulty paying for basic expenses

Yes

No

Thoughts of killing or harming myself

Yes

No

Attempts to kill or harm myself

Yes

No

Hear or see things that other people do not

Yes

No

15. Are you:

Married

Single

Domestic Partnership

Divorced

Widowed

Name of spouse/significant other:

Are you employed?

Yes

No

Occupation:

16. Do you have a family (parent, sibling or child) with a history of: Alcohol/Substance Abuse

Yes

No

Anxiety

Yes

No

Depression

Yes

No

Eating Disorder

Yes

No

Obsessive Compulsive Disorder

Yes

No

Schizophrenia

Yes

No

Suicide

Yes

N

If other, please specify:

17. Please submit a copy of the diagnosis report.

18. Please submit any IEP forms or other forms pertaining to your child's diagnosis of ASD.

Please inform us of the most ideal time and days that you are looking for service..

Thank you for contacting us.
We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

Give Us a Call

888 365 8850

Send a Fax

303-616-1189

Get in Touch with Us

info@inclusiveaba.com

Mon-Fri: 9Am to 5.30 Pm
Sat- Sun: Closed

About Us

At Inclusive ABA, our commitment lies in empowering families and communities by providing them with the tools needed to compassionately embrace autism.

Quick Links

Home
About
- About
- Process
Services
Careers
Locations
- Nevada
- Nebraska
- Colorado
- Utah
- Iowa
- Ohio
Insurance
Blog

Locations

Colorado: 155 Boardwalk Dr Fort Collins, CO 80525

Nevada: 8275 South Eastern Ave Las Vegas, NV 89123

Nebraska: 5000 Central Park Drive Lincoln, NE 68504

© All rights reserved Inclusive ABA

Website by CWS

Share by: