Home
ABA Services
Intake
Consultation
Join our team
Contact Us

Home
ABA Services
Intake
Consultation
Join our team
Contact Us

Intake Form

Interested in receiving services?

Fill out some info and we will be in touch shortly! We can't wait to hear from you.

Your Name*

Home Address*

Phone Number*

Email*

Child's Name*

Child's Age*

Does your child have an official Autism diagnosis by a medical professional?*

Yes

Does your child have other diagnoses? *

What insurance does your child have?*

Horizon BCBS

Horizon NJHealth (Familycare)

Aetna

Have you verified with your insurance provider your plan's coverage for in-home ABA therapy? Are you aware of co-pays, deductibles, etc.?*

Insurance Member ID:*

Subscriber name

Subscriber DOB

Effective/Start Date

What are your main concerns?*

Communication Skills

Social Skills

Self-Help Skills

Leisure Skills

Home Living Skills

Pre-Academic Skills

Safety Skills

Independence

Mild Interferring or Inappropriate Behaviors

Severe Problem Behavior

Coping and Tolerance Skills

Compliance with Demands

Trouble Staying in School

Issues in the Community

In your own words, why are you seeking in-home ABA therapy?*

Has your child received ABA in the past?*

Does your child receive other related services (e.g., speech, physical, occupational therapy, DIR)?*

What is your child's current school placement?*

What is your availability for sessions?*

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

What is your Weekday time-frame availability?*

Mornings (8 am-12 pm)

Afternoons (12 pm-3 pm)

After School (3 pm-6 pm)

Evenings (6 pm-8 pm)

None - Weekends only

What is your Weekend time-frame availability?*

Morning (8 am-12 pm)

Afternoon (12 pm-4 pm)

Evenings (4 pm-8 pm)

None - Weekdays only

Preferred Start Date*

Individualized Supports
Proudly serving families throughout Central New Jersey.

Contact: SCooper@individualizedsupports.com