Intake Form

This form mirrors Propel ABA’s paper intake. Submit handling can be connected to email or a backend later.

Client Information

Name *

Date of Birth *

Address

Phone Number

Email *

Insurance Company

Insurance #

Diagnosing Doctor

Date of Diagnosis

Pediatrician

Pediatrician Phone

Parents’ Names / Phone Numbers

Siblings — Names / Ages

Other Family Members in the Home

Medical & Development

Medical History (seizures, vision/hearing, recurrent illness, etc.)

Allergies or Dietary Considerations

Medications (length of time, reason)

How does your child sleep?

Feeding (concerns, food repertoire, favorite foods)

Other Services (Speech, OT, frequency)

School

Grade / Type of Class

Prior ABA Therapy (home or center)

Preferred Activities

Communication & Social

How does your child communicate? (Verbal, PECS, AAC, etc.)

How often / when do they communicate most?

Receptive Language

Play Skills (parallel/reciprocal, functional play)

Relationships with Others (parents, siblings, adults, peers)

Self-Care

Toileting

Washing Hands

Brushing Teeth

Dressing

Eating

Other Self-Help Concerns

Challenging Behaviors

Does your child display any of the following? Describe each that applies.

Aggression

Bolt

Flop

Tantrum

Environmental Destruction

Non-Compliance

Stereotypy

Other

Typical Triggers

What Behaviors Look Like

Typical Duration

Times Per Week

Self-Injurious Behaviors

Do you ever have to restrain your child?

Community Participation

Behavior in the Community

Community Activities

Scheduling Availability

Enter preferred days/times (e.g. “Mon 3–6”).

Day	8–12	12–3	3–6
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Review risks of email/text for PHI. Select all that apply.

Email communications

Text communications

I do not wish to communicate via email or text

Parent / Legal Guardian Name

Date