Client (Child) Information Child's Full Name*
Date of Birth*
Gender* Male Female Other
Preferred Language
Home Address — Street*
City*
State*
Zip*
Does the child live at more than one home?* No Yes
For example, time split between two parents' homes or with grandparents. Your availability below can then say which home each time applies to.
Parent/Legal Guardian Name(s)*
Relationship to Child*
Does anyone else share legal custody of the child?* Yes No
Primary Phone Number*
Primary Email Address*
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone*
Insurance / Funding Information Primary Insurance Carrier*
Member ID*
Group Number
Name of Insured (if different)
Insured's Date of Birth
Employer (if applicable)
Insurance Card — Back (photo or scan)
Other Funding Source (if any) Medi-Cal School District Regional Center Private Pay Other
Do you authorize us to verify your insurance benefits on your behalf?* Yes No
Service & Scheduling Information Best Method of Contact* Phone Email Text Message
Your Availability for Sessions* 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. For each time, tell us where your child will be (home or school).
Select every day you're available:
Mon Tue Wed Thu Fri Sat Sun
If your schedule changes later (new school year, summer break), you can always share updated availability with our team.
Location of Services Home School Community Telehealth Other
Who will typically be present during sessions (if applicable)
Pets in the Home: Are there any pets in the home?* Yes No
Medical & Developmental Information Primary Care Physician Name
Physician Phone
Diagnoses (if any)
Date of Diagnosis
Diagnosing Provider/Facility
Do you have a copy of the diagnostic evaluation report?* Yes No Not sure
Insurance plans require this report to authorize ABA services — sharing it early speeds up the process.
Current Medications
Relevant Medical History None Seizures Hospitalizations Surgery Other
Strengths of the Child
Primary Concerns / Reason for Seeking Services*
Educational & Service History Current School
Grade/Classroom Setting
Does the child have any of the following? IEP IFSP 504 Plan None
Other Services Currently Receiving Speech Therapy Occupational Therapy Physical Therapy Counseling None Other
Previous ABA Services* Yes No
Behavior & Functional Details Describe behaviors of concern
Any safety concerns? Elopement Self-injury Aggression None Other
What motivates your child? (favorite foods, toys, activities)
Your top goals for your child
Consent & Acknowledgements Please check each box to acknowledge.
I certify that all information provided is accurate to the best of my knowledge.* I authorize Behavia Therapy to verify insurance benefits on my behalf.* I consent to ABA or related services for my child.* I understand that if my child's services are funded through a commercial insurance plan or private pay, I am responsible for the cost-sharing (copays, coinsurance, or deductibles) my plan assigns, and that families funded through Catalight or Medi-Cal are never billed by Behavia Therapy. (Regional Center may help with co-payments — please contact your service coordinator.)* I acknowledge that I have reviewed or will review the Privacy Policy and Terms of Use .* I acknowledge that I have been provided access to Behavia Therapy's HIPAA Notice of Privacy Practices .* I authorize Behavia Therapy to communicate and exchange information with medical, educational, and therapeutic providers when needed for coordination of care.*
Signature Parent/Guardian Full Name*
Relationship to Child*