Client Intake Form

Now accepting new clients! Accepting Insurance: Aetna, Blue Cross of California, Carelon

Personal and Demographic Information

Full Name

Date of Birth

Home Address

Primary Diagnosis(es)

School/Program Attends

Current Grade Level

Guardian/Primary Contact Information

Guardian 1 Full Name

Relationship

Primary Phone Number

Email Address

Guardian 2 Full Name

Relationship

Secondary Phone Number

Clinical and Medical History

Referring Physician/Specialist

Date of Most Recent Diagnostic Report

Current Medications

Allergies

Past ABA Services?

Current Therapies

Safety Concerns

Funding and Insurance Information

Primary Insurance Carrier

Member ID / Policy Number

Group Number

Policy Holder's Full Name

Policy Holder's DOB

Is this policy through Medi-Cal/HMO?

Regional Center Affiliation?

Scheduling and Service Preference

Preferred Service Setting (Initial)

Availability (Please check all possible times/days)

Availability

Guardian Acknowledgement

I certify that the information provided above is true and accurate to the best of my knowledge. I understand that Adonai Behavioral Solutions requires this information to verify coverage and initiate services. I have received and reviewed the Client Service Agreement outlining cancellation policies and financial responsibilities.

Guardian Signature:

Date