Client Registration Form

Client Information *

First

Last

DOB

Age

Gender *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Mother's Information

Mother's Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

DOB

Home Phone

Cell Phone *

Work Phone

Email *

Occupation

Employer

Insurance Carrier

Father's Information

Father's Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

DOB

Home Phone

Cell Phone *

Work Phone

Email *

Occupation

Employer

Insurance Carrier

Siblings/Household Members (Other than parent/guardian)

Name *

First

Last

DOB

Relationship to Child

Name *

First

Last

DOB

Relationship to Child

Name *

First

Last

DOB

Relationship to Child

Emergency Contact Information

Name *

First

Last

Phone

Relationship to Child

Name *

First

Last

Phone

Relationship to Child

Other Services Provided (Speech/PT/OT, etc.)

Name of Provider

Services Provided/Times per week

Name of Provider

Services Provided/Times per week

Name of Provider

Services Provided/Times per week

Diagnosis

Primary Diagnosis 1

Diagnosis Date(s)

Diagnosing Professional

Primary Diagnosis 2

Diagnosis Date(s)

Diagnosing Professional

Primary Diagnosis 3

Diagnosis Date(s)

Diagnosing Professional

Medical Conditions (if any)

Allergies

Diagnosing Professional

Special Diet Information

Current Medications (list them)

Child's Educational Background

School

Grade

Check the box

Home School
General Education
IEP
504

Please list any other important information you would like us to know about your child.

Informed Consent

Client Name *

First

Last

DOB

Do you confirm this information is correct? *

I agree to have my child evaluated/treated by Autism Behavior Support, LLC. I understand that these services are based on an Applied Behavior Analysis (ABA) model and will be provided by a professional trained in ABA. I understand that state laws may require that confidentiality be broken under certain circumstances, specifically, if I am judged by the behavior analyst to be of danger to myself and/or others, gravely disabled, or if there is suspected child abuse. I also understand that Autism Behavior Support, LLC specializes in the evaluation and treatment of problem behaviors as well as skill acquisition, and if Autism Behavior Support, LLC is unable to meet my particular needs, I will be referred to an appropriate agency or individual. Services: Autism Behavior Support implements the Applied Behavior Analysis for its services. A variety of techniques are integrated and utilized during treatment. You will be encouraged to practice various skills introduced in sessions. A treatment plan with specific goals will be explored and updated according to treatment plan schedules. Recommendations for additional treatment and/or intensive treatment may be made, if needed. When a client is a minor under the age of 14, parent involvement is required during all visits with the client. Information will be limited to accommodate confidentiality with children of all ages. Family involvement is an important part of treatment. Children under the age of 18 will require a parent’s signature (or legal guardian) to receive any form of treatment.

Patient/Carer/Guardian Signature *

Date *