In Take Forms – Champions ABA Therapy

Instructions:

Please complete and submit this screening form to schedule an appointment for an evaluation. You may submit this completed form to:

E-mails:

admin@championsabatherapy.com
eonyirimba@championsabatherapy.com

Fax: +1 (678) 388 0639

The following is a comprehensive list of what will need to be provided. Numbers 1-5 can be sent to BCBA via email (BCBA@championsabatherapy.com) before the initial meeting or given to BCBA in person. Numbers 6-7 can be addressed during the initial meeting.

Your child’s most recent IEP/BIP
Records of therapy (previous and current) for your child.
Diagnostic Information
Insurance Cards (if applicable)
Any documents related to services being received such as past intervention reports, or other relevant documents.
Any special accommodation your child may use, such as a chewy, weighted blanket, communication devices.
BCBA/BCaBCA will have additional questions regarding :

Specific items your child is reinforced by

Developmental history
Sleep schedule
Communication skills
Adaptive skills (potty training)
Problem Behaviors

Please answer to the best of your ability. If you do not know any answers, your Stepping Stones ABA Supervisor will work with you closely to determine if it is relevant information necessary for treatment.

BIOGRAPHICAL

Child 's First Name

Child 's Last Name

Sponsor ID/Insurance Subscriber ID:

How Many Caregivers/Legal Guardians Does The Child Have?

Caregiver/Legal Guardian #1

Caregiver/Legal Guardian #1: Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone - Home

Phone - Mobile

Phone - Work

Caregiver/Legal Guardian #2

Caregiver/Legal Guardian #12 Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone - Home

Phone - Mobile

Phone - Work

Who Lives in the Home? (please include any pets so we can ensure proper employee placement for your home)

CURRENT MEDICAL/SCHOOL INFORMATION

School Information (Add Name of School Teacher, Address & Phone Number)

Primary Care Physician (Add Name/Affiliation, Address & Phone Number)

Does your child have an active IEP?

What grade level and placement setting does your child have at school? (i.e. EC Classroom, Gen. Education Setting, Resource)

If permitted, ABA services can be provided in school for your child. This is based on district permissions and your child’s specific needs. Are you looking to have school-based services in conjunction with home-based services for your child?

Yes

Not Applicable

Other Service Providers (Speech/OT/etc.):

Medical/Behavioral History

Autism Diagnostic Info

Diagnosing Date (month/year):

Facility of Diagnosis (Name/State):

Current Medications

History of Seizures

Family History of Autism or related disorders (i.e. OCD, ADHD, etc.)

Diagnosing Provider (name/credentials):

Level of Diagnosis (i.e. 1, 2, or 3):

Allergies

Any other Diagnoses (if none, please indicate):

Please describe the Family History of Autism or List the Related Disorders

Behaviour

Does your child have a history of aggressive behavior that can cause harm to self or others?

Please provide a brief overview (what it looks like, why it typically happens, and how often/how long the behavior can occur):

Have there been any specific behavior interventions previously implemented for your child?

MAIN AREAS OF CONCERN

What is your child’s main form of communication? Please check all that may apply

Verbally (with delays)

Verbally (age-appropriate)

Non-verbally (gestures only)

Communication Device

Picture Exchange (PECS)

Other

If Other Form of Communication, Please State:

In regard to receiving ABA services, what are your main areas of concern you would like to see an increase/decrease in with your child?

Does your child have any sensory-related needs and/or aversions related to sights, smells, or sounds?

State your child's sensory-related needs and/or aversions related to sights, smells, or sounds?

Is there any other information important for Champion’s ABA Therapy Center to be aware of in relation to your child that could impact ABA services?

State any other information important for Champion’s ABA Therapy Center to be aware of in relation to your child that could impact ABA services?

PRIOR PROFESSIONAL CONTACTS

PLEASE LIST ALL PAST AND CURRENT THERAPIES YOUR CHILD HAS RECEIVED BY COMPLETING THE FIELDS BELOW

Occupational Therapy

Start/End Date (Month/Year)

Length of Sessions (In Minutes/hrs.)

Effect of Therapy

How Often? (times per week/month)

Main Targeted Goals

Contact Information of Therapist

Physical Therapy

Start/End Date (Month/Year)

Length of Sessions (In Minutes/hrs.)

Effect of Therapy

How Often? (times per week/month)

Main Targeted Goals

Contact Information of Therapist

Speech

Start/End Date (Month/Year)

Length of Sessions (In Minutes/hrs.)

Effect of Therapy

How Often? (times per week/month)

Main Targeted Goals

Contact Information of Therapist

Early Intervention

Start/End Date (Month/Year)

Length of Sessions (In Minutes/hrs.)

Effect of Therapy

How Often? (times per week/month)

Main Targeted Goals

Contact Information of Therapist

Other (Please indicate):

Start/End Date (Month/Year)

Length of Sessions (In Minutes/hrs.)

Effect of Therapy

How Often? (times per week/month)

Main Targeted Goals

Contact Information of Therapist

Contact Info

Please Complete the In-Take Form & Submit the Other Policy Agreements

Self Pay Itemized Agreement - Download Document

HIPPA Policy - Download Document

Release of Liability - Download Document

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