Intake Form

Name*

Parent or Legal Guardian Name

Address*

How did you hear about us?*

Preferred language during service

Daycare Information (if applicable)

Address

Contact Information

Primary Phone*

Secondary Phone

Date of Birth*

Email*

Ethnicity

Gender

Male

Female

Your Comments*

Name

Number

Days and Hours Desired for ABA Services

Minimum 10 Hours Required

Sundays*

Available

Not Available

Sunday Start Time

Sunday End Time

Mondays*

Available

Not Available

Mondays Start Time

Mondays End Time

Tuesdays*

Available

Not Available

Tuesdays Start Time

Tuesdays End Time

Wednesdays*

Available

Not Available

Wednesdays Start Time

Wednesdays End Time

Thursdays*

Available

Not Available

Thursdays Start Time

Thursdays End Time

Fridays*

Available

Not Available

Fridays Start Time

Fridays End Time

Saturdays*

Available

Not Available

Saturdays Start Time

Saturdays End Time

Total Weekly Hours ABA Service Desired*

Description

Insurance Information

Primary Insurance*

Subscriber ID

Group #

Name of Insured | Policy Holder*

Policy Holder Date of Birth*

Relationship to Patient

Secondary Insurance

Subscriber ID (Secondary)

Group # (Secondary)

Insurance Card | FRONT*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 32 MB.

Please upload an image of the FRONT of your Insurance Card.

Insurance Card | BACK*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 32 MB.

Please upload an image of the BACK of your Insurance Card.

Autism DIAGNOSIS Report (IEP is not accepted by Insurance)*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 32 MB.

Please upload a copy of your Autism DIAGNOSIS or IEP

Medical Necessity Letter / Referral Letter (The document must be signed by a medical officer within the last six months.)*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 32 MB.

Emergency Contact Information

Name*

Phone*

Relationship to Patient

HIPAA Acknowledgement

Consent

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health insurance portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize Rainbow ABA to use and disclose my protected health information to carry out: • Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment) • Obtaining payment from third-party payers (e.g. my insurance company) • The day-to-day healthcare operations of Rainbow ABA. I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact Rainbow ABA at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

Patient Name*

E-Signature*

Signature Date*

Relationship to Patient

Patient Information

Contact Information

Days and Hours Desired for ABA Services

Minimum 10 Hours Required

Insurance Information

Emergency Contact Information

HIPAA Acknowledgement

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