Client Intake Form

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AZ: (480)-389-4516 | MT: (406)-272-8288 | NV: (725)-214-0901 | TX: (214)-785-6585

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: *

English

Spanish

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: *

Current Therapy Location/Agency: *

Any Medications? (Select one): *

Yes

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.

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Client/Parent Signature: *

Date: *

DD/MM/YYYY

If you are human, leave this field blank.

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Mesa, AZ 85212

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Gilbert, AZ 85297

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