client-form - Atlas Behavior

Client Information

Please 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

Address

Social Security No.

Date of Birth

Parent/Guardian Information

We may need to contact you for further information or consent related to our behavior services.

Mothers Name

Date of Birth

Social Security No.

Home Phone

Cell Phone

Email Address

Occupation

Employer

Insurance Carrier

Policy Number

Address

Father Name

Date of Birth

Social Security No.

Home Phone

Cell Phone

Email Address

Occupation

Employer

Insurance Carrier

Policy Number

Address

Other Insurance Coverage

This information helps us coordinate and maximize the benefits available for our behavior services.

Policy Holder

Insurance Carrier

Insurance Policy No.

Insurance Group No.

Siblings/Household Members (Other than parent/guardian)

Please provide information about any siblings or other household members who are not the parent or guardian.

Full Name

Age

Relationship

Full Name

Age

Relationship

Siblings/Household Members (Other than parent/guardian)

Please provide information about any siblings or other household members who are not the parent or guardian.

Full Name

Relationship to Child

Phone Number

Full Name

Relationship to Child

Phone Number

Other Services Provided (Speech/PT/OT, etc.):

This information is crucial for us to provide comprehensive care and support.

Name of Provider

Services Provided/Times per week

Other Services Provided (Speech/PT/OT, etc.):

This information is crucial for us to provide comprehensive care and support.

Primary Diagnosis 1

Diagnosis Date(s)

Diagnosing Professional

Medical Conditions (if any)

Allergies

Diagnosing Professional

Special Diet Information

Current Medications

Please list any current medications that the child or individual is taking.

Medication

Dosage

Frequency

Available Services Times

Please indicate the times during which you are available for services.

Monday

:

Tuesday

:

Wednesday

:

Thursday

:

Friday

:

Saturday

:

Problem Behavior Information

"Please provide details about any problem behaviors or challenges the child or individual may be experiencing.

Behavior (Please describe)

Frequency (hourly, daily, weekly, less often, more often, etc.)

Duration (how long does the behavior occur)

Severity

What current treatments are being implemented?

What treatments have been implemented in the past?

What motivates/interests your child?

Please list any other important information you would like us to know about your child.