First Name *

Last Name *

Child's Name *

Relationship to Child *

Child's Date of Birth *

Email *

Phone Number *

Address *

State *

ZIP Code *

Country *

Insurance (ex. Medicaid, BCBS, Aetna) *

Insurance ID *

Diagnosis (ex. Autism, ADHD, etc.) *

Name of School *

Services Received in School? *

Yes

Pediatrician's Name *

Pediatrician's Phone Number *

Current Medications (and times of administering) *

Reason for requesting services *

Other private services received *

ABA Therapy

Speech Therapy

School Collaboration

Parent Training & Support

Other

Availability for Session:Center-Based ABA sessions are typically provided 5 days per week. Please select which time block works best for your child. Session times are subject to change based on clinical recommendation.

If you have flexibility during the day, please check both boxes. *

A: 8:00am - 12:00pm

B: 12:00pm - 4:00pm

C: 4:00pm - 6:00pm

Extended Day (between 8:00am and 6pm)

How did you hear about our services? *

Social Media (Facebook, Instagram, etc.)

Word of Mouth (Friend/Family/School)

Internet/Google

I am a current Shining Star Clinic ABA client

Other

Upload Insurance Card (Front) *

No Choosen File

(Max 10 MB)

Upload Insurance Card (back) *

No Choosen File

(Max 10 MB)

Upload Autism Diagnostic Report (if available)

No Choosen File

(Max 2 MB)

Please upload your child’s most recent autism evaluation or diagnostic report (e.g., ADOS, ADI-R, psychological assessment). This helps us verify eligibility for ABA services. If you don’t have one yet, we’ll help you schedule an evaluation

Parent/Guardian Signature (Use your mouse or finger to sign below) *

Consent & Acknowledgment By signing below, I confirm that: The information provided in this form is true and accurate to the best of my knowledge. I authorize Shining Star Clinic – ABA Therapy Center to contact me by phone, email, or text regarding my child’s services. I consent to the collection and secure storage of my child’s information for the purpose of service eligibility, scheduling, and insurance verification. I understand that submitting this form does not guarantee admission and that services begin only after assessment and authorization.

Intake Form

Shining Star Clinic – ABA Therapy Intake Form

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