Intake Form - Juvo Autism + Behavioral Health Services

Client Information

Name of Client*

First Last

Diagnosis*

Client's Date of Birth*

Age

Please enter a number from 0 to 120.

Gender

Home Address*

Street Address Address Line 2 City State ZIP Code

Is Service Address different than your Home Address?*

Yes
No

Service Address*

Street Address Address Line 2 City State ZIP Code

Prior ABA?

Prior Counseling?

Grade Level

School

Contact Information

Your Name*

First Last

Your Relationship to Client*

Your Phone Number*

Your Email*

Located at Address Above*

Yes
No

Your Address*

Street Address Address Line 2 City State ZIP Code

Additional Contact Information

Additional Contact - Name

Additional Contact - Relationship

Additional Contact - Phone

Additional Contact - Email

Emergency Contact Information

Emergency Contact Name

First Last

Emergency Contact Relationship to Client

Emergency Contact's Phone Number

Emergency Contact's Email

Intake Information

Medical Insurance Company

Timeslot*

8AM-3PM
12PM-3PM
3PM-8PM

Referral Source (How they heard about us)

Private Insurance
School District
Regional Center
Physician's Office
Employee
Parent
Magazine
Internet Search
Other

Referral Source(s) Details

Notes (Areas of concern, special staffing needs, etc).

We would like to ask you some questions about your Client's routines. The purpose of obtaining this information is to ensure we can provide an appropriate schedule.

Home Schedule

Wake-Up Time

: HH

MM

Nap Time

: HH

MM

Bed Time

: HH

MM

School Information

Is the client in school?

Yes
No

School Name

School Location

School Schedule

How does the client get home from school?

Picked Up
Bus

Does the parent have any plans for enrolling them?

Yes
No

Extra Curricular Activities

Activity (Extra Curricular)

Schedule (Extra Curricular)

Other Medical Services (SLP, OT, PT, ETC)

Type of Therapy (Other Medical Services)

Schedule (Other Medical Services)

Special Staffing Considerations

The next couple questions I will be asking are to ensure that we assign appropriate staff.

Are there pets in the home?

Yes, Indoor Pets
Yes, Outdoor Pets
No

List the Type(s) of Pet(s)

Does anyone smoke inside the house?

Yes
No

Client's Allergies

Other location details / parking restrictions or gate codes

Reasonable Schedule Offer Disclosure

Our responsibility is to offer you a full reasonable schedule, which means that we will offer you a schedule that fulfills the number of hours recommended by the assessing clinician and during a time that does not conflict with school or other medically necessary services already scheduled.

Do you agree to the above?

Yes
No

CAPTCHA

Juvo's Intake Form

Initial Intake Form

Client Information

Contact Information

Emergency Contact Information

Intake Information

Home Schedule

School Information

Extra Curricular Activities

Other Medical Services (SLP, OT, PT, ETC)

Special Staffing Considerations

Reasonable Schedule Offer Disclosure