Client Intake Form Online Client Intake Form-Part 1 Critical Information Client's First / Last Name: * Client's DOB: * MM/DD/YYYY Primary Contact First / Last Name: * Primary Phone #: * Primary Email: * Primary Address: * City: * State: * Zip Code: * Secondary Contact First/Last Name: * Secondary Contact Phone # and/or Email: * Services Needed (select all that apply): * Habilitation Respite ABA Speech Therapy Occupational Therapy Psychological Eval Preferred Language for Oral Communication/ Idioma preferido para la comunicación oral/ Langue préférée pour la communication orale: * English Spanish Mandarin French Arabic OtherOther Preferred Language for Written Communication/ Idioma preferido para la comunicación escrita/ Langue préférée pour la communication écrite: * English Spanish Mandarin French Arabic OtherOther Primary Physician's Name: * Physician's Phone Number: * Client's School: * School Attendance Days and Times: * Client's Current Services: * Therapy Location/Agency: * Any Medications? (Select one): * Yes No If yes, please specify medications: Primary Insurance Company Name: * Primary Insurance Policy Holder Name: * Primary Insurance Policy Holder DOB: * Primary Insurance Policy Holder Employer: * Primary Insurance Policy Number (required): * Primary Insurance Group Number (required): * Secondary Insurance Plan: * DDD/DDP Coordinator Name: * DDD/DDP Coordinator Email/Phone: * Please Upload documents if available 1) Photo of your Insurance Card- Front and back 2) Your Diagnostic Evaluation 3) Copies of any Prescriptions File Upload Drop a file here or click to upload Choose File Maximum upload size: 314.57MB I Understand and Consent to the following: * I provide consent for AACT to bill my insurance and I acknowledge that I will be responsible to pay should there be no coverage. I understand AACT may share information and discuss this case with Therapists, Medical Doctors and other authorized individuals in order to treat the client. I understand I have the right to refuse treatment at anytime. I acknowledge that AACT does not solicit clients and I have chosen AACT of my own volition. reCAPTCHA Client/Parent Signature: * Date: * DD/MM/YYYY If you are human, leave this field blank. Next
