Assent Behavioral Services LLC

WAITLIST NOTICE

Thank you for your interest in Assent Behavioral Services. Your intake submission has been received, and your child has been placed on our service waitlist. Our waitlist is actively monitored, and families are contacted as appropriate service openings become available. Please note that placement on the waitlist does not guarantee that services will be provided, as availability depends on clinical capacity, staffing, scheduling, and funding authorization. We understand how important support is for your family and will reach out if an appropriate opportunity for services arises. You are welcome to contact us at any time with updates or questions.

Today's Date *

Name of Child *

Child's Date of Birth (DOB) *

Address where child currently resides *

Funding Source

Primary Insurance provider

Insurance ID or Contract number

Insurance Card (Front)

Attach image of insurance card (Front)

Insurance Card (Back)

Attach image of insurance card (Back)

Secondary Insurance Policy

Ignore question if there is no secondary insurance/policy

Please list child's diagnoses. Note: Child must have a formal autism diagnosis for insurance to cover ABA services. *

If none write N/A

Medications and Dosage *

If not applicable write N/A

Does your child have allergies? Please list or write n/a. *

Does your child experience seizures/or have a seizure disorder? *

Note: It's Assent Behavior Services LLC's policy to contact emergency services (911) in the event of a medical emergency while on premises.

E-Signature: REQUIRED. Parent/Legal Guardian Consent and Agreement for Emergencies:  As parent/legal guardian, I give consent to have my child receive first aid by ABS staff, and, if necessary, be transported to receive emergency care. I understand that I will be responsible for all charges not covered by insurance. I agree to review and update this information whenever a change occurs and at least once a year. *

Signature is required

Name of school child attends (N/A if not enrolled)

Has your child received ABA therapy before? *

Please indicate your availability for services *

Monday 8:30am - 12:30pm (Morning Session)

Monday 1:30pm - 5:30pm (Afternoon Session)

Tuesday 8:30am - 12:30pm (Morning Session)

Tuesday 1:30pm - 5:30pm (Afternoon Session)

Wednesday 8:30am - 12:30pm (Morning Session)

Wednesday 1:30pm - 5:30pm (Afternoon Session)

Thursday 8:30am - 12:30pm (Morning Session)

Thursday 1:30pm - 5:30pm (Afternoon Session)

Friday 8:30am - 12:30pm (Morning Session)

Friday 1:30pm - 5:30pm (Afternoon Session)

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? *

Example: Communication, Behavior, Independence Skills, Social Skills, etc.

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

If you answered Yes, please explain.

Is there any other important information for Assent Behavioral Services LLC to be aware of in relation to your child that could impact ABA services? *

If you answered yes, explain please.

What are the behaviors or developmental milestones of concern? *

Please list behaviors and describe what each looks like.

When are you likely to see these behaviors occur?

Which behaviors tend to occur together? Describe

Can you identify when the behaviors are going to occur? If so, what steps do you take?

Language: please describe your child's speech ability. *

What is your child's primairy form of communication.

Check all that apply.

Verbally (With delays)

Verbally (Age appropriate)

Non-verbally (Gestures only)

Communication Devices

Picture Exchange (PECS)

Describe how your child indicates their wants/needs.

Describe your childs ability to imitate vocal sounds, words, and phrases.

Social: please describe your child's ability to socialize with same age peers. *

Parent/Guardian Name *

Emergency Contact Name (If guardian isn't available) *

Parent/Guardian Phone Number *

Emergency Contact Phone Number *

Parent/Guardian Email Address *

Intake Screening Form (Clinic)

Intake Screening Form (Clinic)

WAITLIST NOTICE

Intake Screening Form (Clinic)