Language English (US) Spanish (Latin America) Intake Form Name of Client* First NameLast Name Medicaid Number* D.O.B* -Month -DayYearDate Mother's Name* First NameLast Name Father's Name* First NameLast Name Emergency Contacts* Best Contact Number* Please enter a valid phone number. Email Address* example@example.com Address* Street Address Street Address Line 2 CityState / Province Postal / Zip Code Have you ever had ABA Therapy* YesNo Name of prior ABA Provider (If applicable) Please list all known allergies(If none type N/A) * Are we also able to contact you via text?* YesNo Please list the days you are available* Location of Services* In-Center School Name (If applicable)* Any important information about he client we should know?* What are some behaviors that concern you (Client Maladaptive Behaviors)* Primary Language* How did you hear about us?* Submit Should be Empty: