Patient Intake Form
Provides the information needed to review eligibility, understand clinical needs, and begin the intake process.
01
Intake & Consent
Consent to Treat
Authorizes evaluation and treatment and explains the general scope of ABA services.
Informed Consent for Applied Behavior Analysis (ABA) Services
Explains ABA services, responsibilities, potential benefits and risks, privacy, and the right to consent voluntarily.
02
Privacy & Coordination of Care
Notice of Privacy Practices
Acknowledges receipt of information describing how protected health information may be used and disclosed.
Consent to Release Information (ROI)
Authorizes the use, disclosure, release, or receipt of specified protected health information.
Coordination of Care Authorization
Authorizes communication and coordination with selected healthcare, educational, and service providers.
03
Activities & Release Agreement
Consent, Assumption of Risk, Authorization, and Release Agreement
Covers transportation, swimming and aquatics, community outings, and field trips. Review the entire agreement before signing.