APPLY FOR ABA SERVICES

Client Intake Packet
Applied Behavior Analysis

CONFIDENTIAL

Please complete this intake questionnaire regarding your child to the best of your ability. Feel free to add any additional information or attach additional reports that you think may helpful for us in getting to know your child. Manawa views all of the information that you provide us with as strictly confidential. This information is helpful for us in developing an initial understanding of your child’s needs and provides critical information for us to discuss with your insurance company to get authorization for services.

Today's Date

Legal Name of Client

Client's Preferred Name/Nickname

Select a date

Client's Age

Client's Gender

Male

Female

Client's Home address

Client's Mailing Address

PARENT/GUARDIAN INFORMATION

Parent/Guardian # 2 Name:

Parent/Guardian #1 Home Address:

Parent/Guardian #1 Cell Phone Number:

Parent/Guardian #1 Email Address:

Preferred Method of Contact:

Call

Text

Post

Parent/Guardian #2 Name:

Parent/Guardian #2 Home Address:

Parent/Guardian #2 Cell Phone Number:

Parent/Guardian #2 Email Address:

Preferred Method of Contact:

call

text

post

INSURANCE INFORMATION

*Please provide us with a copy of the front and back of your insurance card if you are going to be seeking reimbursement for services through your insurance company

Name of Insurance Company

Name of Policy Holder

Social Security Number

Date of Birth

Insurance Member ID

Group ID

Quest?

not sure

yes

Copay?

not sure

yes

Amount of Copay (if applicable)

MEDICAL INFORMATION

Name of Referring Provider

Referring Diagnosis/Age of Diagnosis

Please list any additional diagnoses client has

Please list any serious illnesses, conditions, injuries, or hospitalizations - client has experienced

Does Client have:

Vision Problems?

Yes - Describe

Allergies?

Yes - Describe

Hearing Problems?

Yes - Describe

Current Medications?

Yes - Describe

CLIENT HISTORY

Please provide us with information regarding the following types of current or previous therapy providers and copies of any recent evaluations that indicate dates of previous treatment and therapeutic interventions and responses.

CURRENT/PREVIOUS PROVIDER INFO

Has Client Received ABA Services in the Past?

Yes

If yes, please provide company and dates of treatment

Does Manawa have permission to contact provider?

Yes - Contact info:

Yes

Has Client Received Speech Therapy in the Past?

If yes, please provide company and dates of treatment

Does Manawa have permission to contact provider

Yes - Contact info:

Please list any other therapies or providers client sees on a regular basis:

EDUCATIONAL INFO

Please provide us with a copy of your child’s current Individualized Education Plan (IEP) if applicable

Name of Current School

Current Grade

Please list any Special Education Accommodations Client has

Previous Schools/Grades Attended

BIRTH AND DEVELOPMENTAL HISTORY

Did mother receive regular prenatal care?

Yes

Were there any complications with the pregnancy?

Yes - Describe

Was birth full term?

Yes - Describe

Were there any complications with the birth?

Yes

Were there any complications with the birth?

Yes

Were there any complications with the birth?

Yes

Were there any concerns at birth?

Yes - Describe

Which developmental milestones was client delayed in or did not achieve?

At what age did caregiver first realize client was not developing typically?

Does either parent/caregiver’s job require them to be away from home for long hours or extended periods of time that might prevent them from being involved in ABA services and parent training?

FAMILY INFO

Yes

If yes, which parent and for how long?

Caregiver’s Marital Status:

Single

Married/ Together

Divorced/ Separated

Remarried/ New Partner

If divorced/separated, who has legal custody?

Is it full or joint?

Are both parent’s on board with ABA services?

Yes

Are there any other individual residing in the house or who play a significant role on how client is raised?

Yes - Describe

Are both parent’s on board with ABA services?

Yes - Name and Age:

CURRENT BEHAVIOR CONCERNS

Please indicate if client engages in any of the following behaviors check all that apply:

Self Injurious Behavior (specify below)

Tantrums

Defiance/Problem with Authority

Property Destruction - Describe:

Eloping (running out of buildings, away from parents, etc) – Describe:

Obsessive/Ritualistic Behaviors- Describe:

Sensory issues- Describe:

Sexualized behaviors - Describe:

Please briefly describe the behaviors you are most concerned with. When do they occur? How long does itlast? Who is usually around? What do they look like? The more information you can provide, the better

How do caregivers normally respond to problem behaviors (time out, yelling, ignoring, etc)?

Is this method normally effective:

Yes

Are there any current or past relevant legal issues pending with client?

Yes - describe:

Client’s strengths (check all that apply):

Client can appropriately communicate their wants and needs

Client has strong family support

Client is dedicated to receiving services

Client has one or more close friends

Client is receiving an education that seems to meet their needs

Other

Client’s needs (check all that apply):

Client does not communicate or needs help communicating effectively

Client does not have a stable support system at home

Client needs assistance with social skills (making and keeping friends)

Client needs assistance maintaining health and safety

Client needs assistance with activities of daily living (bathing, toileting, etc)

Caregiver needs training/support

Other

Is client verbal?

Yes

No Describe how they communicate

ABA SERVICES

If deemed necessary, Manawa can provide ABA services at home and in the community. An adult/caregiver over the age of 18 must be in the home during all sessions. Do you agree to have someone present?

Yes

Does client attend a preschool/day care/ after school program (A+, etc) that would be open to hosting

Yes

Most clients are approved for 3-6 days a week of ABA services. Can your schedule accommodate this many days?

Yes

Manawa has immediate availability for daytime center based services. Home services will only be offered if deemed medically necessary by your clinician.

Availability for Home-Based Services:

Select all days and times that work for your child's schedule. Please note that Manawa follows a "block schedule" for staffing, sanitation, and community purposes. We are unable to accommodate times between blocks or shorten blocks. Mahalo for your understanding

Monday

8am - 11am

11:30am - 2:30pm

2:30pm - 5:30pm

5:30 - 7:30

Tuesday

8am - 11am

11:30am - 2:30pm

2:30pm - 5:30pm

5:30 - 7:30

Wednesday

8am - 11am

11:30am - 2:30pm

2:30pm - 5:30pm

5:30 - 7:30

Thursday

8am - 11am

11:30am - 2:30pm

2:30pm - 5:30pm

Not Available

Friday

8am - 11am

11:30am-2:30pm

2:30pm - 5:30pm

5:30 - 7:30

Saturday

8am - 11am

11:30am - 2:30pm

2:30pm - 5:30pm

5:30 - 7:30

Thanks for submitting!

Mahalo for completing the intake packet! We will use this information to obtain authorization from your insurance company to begin ABA services. Please feel free to reach out with any questions or concerns.

APPLY FOR ABA SERVICES

Client Intake Packet Applied Behavior Analysis​

CONFIDENTIAL

PARENT/GUARDIAN INFORMATION

INSURANCE INFORMATION

*Please provide us with a copy of the front and back of your insurance card if you are going to be seeking reimbursement for services through your insurance company

MEDICAL INFORMATION

Does Client have:

CLIENT HISTORY

Please provide us with information regarding the following types of current or previous therapy providers and copies of any recent evaluations that indicate dates of previous treatment and therapeutic interventions and responses.

CURRENT/PREVIOUS PROVIDER INFO

Has Client Received ABA Services in the Past?

Does Manawa have permission to contact provider?

Has Client Received Speech Therapy in the Past?

EDUCATIONAL INFO

BIRTH AND DEVELOPMENTAL HISTORY

Does either parent/caregiver’s job require them to be away from home for long hours or extended periods of time that might prevent them from being involved in ABA services and parent training?

FAMILY INFO

CURRENT BEHAVIOR CONCERNS

Please indicate if client engages in any of the following behaviors check all that apply:

Client’s strengths (check all that apply):

Client’s needs (check all that apply):

ABA SERVICES

Client Intake Packet
Applied Behavior Analysis