To be completed by a parent or legal guardian. Fill out the required fields, sign electronically (type your name or draw), and submit — our intake team will take it from there.
If none, write N/A.
A clear phone photo works.
Consistent session times are essential for your child to receive consistent services, make progress toward goals, and graduate from ABA. Please share every day and time your child (and a caregiver) can truly be available — more availability helps us match a therapist faster and keep sessions consistent.
Select every day you're available:
If your schedule changes later (new school year, summer break), you can always share updated availability with our team.
Insurance plans require this report to authorize ABA services — sharing it early speeds up the process.
Write None if there are no allergies.
Please check each box to acknowledge.
Your typed name becomes your electronic signature.
No mobile information will be shared with third parties or affiliates for marketing or promotional purposes. View our Privacy Policy and Terms of Use.