New Client Intake Form

First Name of Person Completing Form

Last name of Person Completing Form

Complete First, Middle and Last Name of Incoming Client if Different from Person Completing Form:

Birthday of Incoming Client

Month

Day

Year

Best Contact Phone Number:

Multi-line address

Country/Region

Address

City

Zip / Postal code

Primary Insurance Provider

Primary Insurance Card Front

Primary Insurance Card Back

Does the incoming client have a secondary insurance?

Yes

Secondary Insurance Card Front

Secondary Insurance Card Back

Does the incoming client have an autism diagnosis from within the last three years? If so, please submit the diagnostic report below

Comprehensive Diagnostic Evaluation (CDE) that includes tool used:

Referral to ABA with My Time 2 Launch from Pediatrician or other Medical Provider:

If this is for a school-aged child, do they attend school? If so, please provide the name of the school and upload any IEP below (school attendance and whether there is an IEP in place does not affect ABA eligibility.

IEP

How did you hear about My Time 2 Launch?

New Client Intake Form

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