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Leap Autism Therapy Intake Form
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Email
*
Your email
Parent Name 1 (Insurance Policy Holder)
*
Your answer
Loaction intersted in (based on availability)
706 W Center St Duncanville Texas 75116
1861 Valley View Dr Farmers Branch Texas 75039
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Parent Name 2
*
Your answer
Patient Name
*
Your answer
Patient Date of Birth
*
MM
/
DD
/
YYYY
Insurance company
*
Your answer
Insurance policy number
*
Your answer
Insurance group number
*
Your answer
Address
*
Your answer
Phone number
*
Your answer
email address
*
Your answer
Marital status
*
Married
Single
Divorced
Seperated
Other:
Parent/Guardian(s) with custody of child *
*
Your answer
Diagnosed with Autism
*
Yes
No
Date of Diagnosis
*
MM
/
DD
/
YYYY
Did you receive a referral for ABA Therapy in writing?
*
Yes
No
Other:
Receiving any other therapies?
*
speech
OT /occupational therapy
physical therapy
other
Who lives in the home? (list everyone)
*
Your answer
Behaviors
Check all that apply
Behavior concerns
*
Tantrums
Elopement/running away
Stemming (line up toys, rocking, humming, screaming etc)
Delayed Potty training
Non compiance
Mouthing (placing items near mouth)
Pica (eating non edible objects)
Aggression
Other
Required
Please list any additional behavior concerns (please include frequency per day, how long it lasts, and if it is severe, moderate, or mild in intensity) *
*
Your answer
Additional concerns/needs
*
Your answer
Attend School?
*
yes
No
If attending school school name and grade level
*
Your answer
Placement in school (N/A if not in school) *
*
Gen Ed
Special Ed
Inclusion
Life Skills
Other:
Required
Special Diets? *
*
yes
No
Other:
Has your child exhibited any loss of skills in any area? *
*
Yes
No
Other:
If yes please explain
Your answer
Social and Play skills
Does your child play independently?
*
Yes
No
Other:
Does you child play with toys appropriately? *
Yes
No
Other:
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Does you child attempt to play with others? *
*
Yes
No
Other:
Does you child engage in interactive play or pretend play with other children? (dress up, pretend, hide and seek, tag, etc) *
*
Yes
No
Other:
Communication
Please answer question regarding your child's communication skills.
Communication level
*
Verbal
non verbal
sign language
Alternative communication device
PECS
Other:
Required
Does you child respond when his/her name is called? *
Yes
No
Other:
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Does you child imitate sounds? *
*
Yes
No
Other:
Does you child follow simple instructions? *
*
Yes
No
Other:
Does you child make eye contact? *
*
Yes
No
Other:
Does you child label items/events/actions? (see dog then say dog, see jumping the says jumping etc) *
*
Yes
No
Other:
Does your child answer "WH" questions? (who ,what, when, where) *
*
yes
No
Other:
Does your child have conversations with others? *
*
Yes
No
Other:
Describe how your child communicates what he/she wants? *
Your answer
Does your child have any sensory-related needs and/or aversions related to sights, smells, or sounds?
*
Yes
No
Motor skills
Can your child imitate simple gestures? (waving, clapping) *
*
Yes
No
Other:
Can your child imitate simple gestures using objects? (banging a drum, shaking a noise making toy) *
*
yes
no
Other:
Can your child imitate fine motor gesture? (snapping a button together, picking up a small item with in between 2 fingers) *
*
yes
no
Other:
Describe your child's fine motor skills (buttoning clothes, turning pages, cutting with scissors etc) *
*
Your answer
Describe your child's gross motor skills (catching a ball, jumping, climbing etc) *
*
Your answer
Self help skills
Can your child independently perform any of these self help skills? (check all that apply) *
*
Feed self
Dress self
Potty trained
Clean up after self
Required
History of Seizures?
*
Yes
No
Any other diagnoses?
Your answer
Who is the referring physician? (first name, last name) *
*
Your answer
Referring Physician address (address, city, St, Zip code Phone Number) *
*
Your answer
Medications?
*
Your answer
Allergies?
*
Your answer
Is there any other information important for LEAP Autism Therapy to be aware of in relation to your child that could impact ABA services?
*
Your answer
When do you need to start ABA services?
ASAP
Within 1-2 months
Within the next 3 months or more
How did you here about us?
*
Google
Referral (patient/Dr)
Bing (alexa)
School
Other:
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