Start Your Child’s ABA Journey Today

Complete our intake form to help us understand your child’s behavior and goals. This helps us create a personalized ABA treatment plan.

Confidential

Intake Questionnaire ABA Therapy

Please complete this Intake Form regarding your child. Progressive Option Support Services views all the information that you provide us with as strictly confidential on this HIPAA compliant submission platform. This information is helpful for us in developing an initial understanding of your child’s needs and provides critical information for us to discuss with your insurance company to get authorization for services.

Please upload front and back copies of your insurance card, a copy of the autism evaluation report, and/or a copy of the doctor’s script with ASD diagnosis

A MEMBER OF OUR STAFF WILL CONTACT YOU WITHIN 24HRS

How did you hear of us?
Please select all that apply and provide additional details if necessary.
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Personal Information

First Name (of person completing this form)
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Last Name (of person completing this form)
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i.e Father, Mother
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Child/Adolescent Information

Please enter the child’s legal first name.
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Please enter the child’s legal last name.
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Please mention the accurate date of birth
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Age in years.
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Parent/Guardian Information

Please enter the name of the primary parent/guardian. (First and Last)
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(Optional) Please enter the name of the second parent/guardian. (First and Last)
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Home Address
Please provide the complete home address (Street, City, State, ZIP)
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Please provide the home phone number.
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(Optional) alternative phone number if available.
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Employer Information

Please provide the name of your employer.
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Employer Address
Please provide your employer’s address (Street, City, ZIP).
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Please provide your employer’s phone number.
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Appointment Scheduling

your availability for appointments
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time availability for appointments
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ABA therapy received in last 6 months?
Please indicate if you have received ABA therapy in the last 6 months.
This field is required.

Insurance Information

Please enter the policy holder’s name. (First and Last)
This field is required.
Please enter the policy holder’s date of birth.
This field is required.
Please provide the name of your insurance company.
This field is required.
Please provide your insurance company name
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insurance company phone number.
This field is required.
Please provide your member ID number.
This field is required.
Please provide your group ID number.
This field is required.
Please upload the front of your insurance card.
This field is required.
Please upload the back of your insurance card.
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full report with ASD diagnosis
This field is required.
(Optional) Please upload the child’s IEP or 504 Plan if available.
This field is required.
(Optional) Please upload any speech, OT, or social assessments.
This field is required.