NEW 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): *

Preferred Language for Oral Communication/ Idioma preferido para la comunicación oral:

English

Spanish

OtherOther

Preferred Language for Written Communication/ Idioma preferido para la comunicación escrita/ Langue préférée pour la communication écrite:

Primary Physician's Name: *

Physician's Phone Number: *

Client's School: *

School Attendance Days and Times:

Client's Current Services: *

Current 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: *

Support Coordinator Name: *

Support Coordinator Email/Phone: *

Please Upload ALL of the following documents if available

1)Photo of your Insurance Card- Front and back | 2) Your Diagnostic Evaluation | 3) Copies of any Prescriptions

File Upload

Maximum file 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.

I authorize AACT to send SMS text messages related to provider timecard approvals. Message and data rates may apply.

reCAPTCHA

Client/Parent Signature:

Date:

DD/MM/YYYY

Client Intake Form

Critical Information

Clinic Address

Administrative Office Address

Call Us

Email Us

Time Cards and Billing:

Employee Hiring Packets and Certificate Information:

Recruitment & Family Pairing Questions:

Client Intake Questions:

Habilitation and Respite Questions: