client-form (1) form design 1Client Information2Parent / Guardian #13Parent / Guardian #24Insurance, Household & Emergency5Physician & Diagnosis6Medical & Developmental History7Communication & Daily Living8Services & Education Client InformationPlease provide essential details about yourself or the individual receiving our behavior services. This information is crucial for personalizing our support and ensuring the best possible care.Client Name (First, Last)(Required) First Last Preferred Name / NicknameDate of Birth(Required) MM slash DD slash YYYY AgeGender IdentityPronouns (optional)Primary Language at HomeInterpreter Needed? Yes No Interpreter Language / DetailsClient Mailing Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Parent / Guardian #1 (Primary Contact)We may need to contact you for further information or consent related to our behavior services.Full Name(Required) First Last Relationship to Client(Required)Date of Birth MM slash DD slash YYYY Preferred LanguageHome PhoneCell Phone(Required)Email Address(Required) OccupationEmployerAddress (if different from client) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Insurance Information – Guardian #1Insurance CarrierPolicy NumberGroup NumberCoverage Type Primary Secondary Parent / Guardian #2Full Name First Last Relationship to ClientDate of Birth MM slash DD slash YYYY Preferred LanguageHome PhoneCell PhoneEmail Address OccupationEmployerAddress (if different from client) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Insurance Information – Guardian #2Insurance CarrierPolicy NumberGroup NumberCoverage Type Primary Secondary Other / Secondary Insurance CoverageThis information helps us coordinate and maximize the benefits available for our behavior services.Policy Holder NameRelationship to ClientInsurance CarrierPolicy NumberGroup NumberHousehold Members (Other Than Parent/Guardian)Please provide information about any siblings or other household members who are not the parent or guardian.NameAgeRelationshipNameAgeRelationshipNameAgeRelationshipEmergency ContactsName(Required)Phone Number(Required)Relationship to Client(Required)NamePhone NumberRelationship to Client Referring / Primary Care PhysicianPhysician NamePractice / Clinic NamePhone NumberFax NumberAddress Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Diagnosis InformationThis information is crucial for us to provide comprehensive care and support.Diagnosis #1Primary DiagnosisICD-10 Code (if known)Diagnosis Date MM slash DD slash YYYY Diagnosing ProfessionalDiagnosis #2 (if applicable)DiagnosisICD-10 Code (if known)Diagnosis Date MM slash DD slash YYYY Diagnosing ProfessionalDiagnosis #3 (if applicable)DiagnosisICD-10 Code (if known)Diagnosis Date MM slash DD slash YYYY Diagnosing Professional Medical HistoryMedical Conditions (please describe)Known Allergies (food, medication, environmental)Special Diet / Feeding RestrictionsSeizure History Yes No If yes, describeCurrent MedicationsPlease list any current medications that the child or individual is taking.Current MedicationsUse the + button to add more medications.Medication NameDosageFrequency / Time of Day Add RemoveNo current medications No current medications Developmental HistoryAge when concerns were first noticedWho first raised concerns? Parent/Family Pediatrician School Other Brief developmental history (milestones, birth/pregnancy notes, relevant history) Communication ProfilePrimary Communication Mode (select all that apply) Verbal / Spoken Language Sign Language (ASL or other) Picture Exchange (PECS) AAC Device / Speech Generating Device Written Communication Gestures / Pointing Vocalizations (non-word) Other (describe below) Estimated vocabulary size / average utterance lengthAble to follow 1-step directions 2-step directions Multi-step directions Inconsistent Able to express needs/wants independently Yes No Sometimes Additional communication notesDaily Living SkillsToileting Fully independent Partially trained Not yet trained Uses pull-ups/diapers Dressing Independent Requires prompts Fully dependent Feeding Independent Requires assistance Limited diet / Feeding concerns Sleep No concerns Difficulty falling asleep Frequent night waking Early waking Any other daily living skill concerns Other Services & Current Care TeamPlease list all other providers currently working with your child:Provider NameService Type (Speech, OT, PT, etc.)Sessions per WeekProvider NameService TypeSessions per WeekProvider NameService TypeSessions per WeekChild's Educational BackgroundSchool / Program NameGrade / LevelClassroom Setting (select all that apply) General Education Autistic Support Learning Support Life Skills Emotional Support Speech / Language Home School Private School Other If Other, please specifySchool Contact NameSchool Phone NumberIEP / FBA / BIP DocumentsPlease attach the most recent copy of your child's IEP, FBA, and/or BIP. Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 128 MB, Max. files: 5.