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Client Intake Form

Client's First name*

Client's Last name*

Client's DOB:*

Month

Day

Year

Primary Contact First / Last Name:*

Primary Email:*

Primary Phone #:*

Primary Address:*

City:*

State:*

Zip Code:*

Secondary Contact First/Last Name:*

Secondary Contact Phone # and/or Email:*

Services Needed (select all that apply):*

Habilitation

Occupational Therapy

Psychological Eval

Respite

ABA

Speech Therapy

Preferred Language for Oral Communication:*

English

Spanish

Preferred Language for Written Communication: *

English

Spanish

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:*

Month

Day

Year

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

Drop a file here or click to 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.

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

Client/Parent Signature:*

Date*

Month

Day

Year

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