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Intake Form

Shining Star Clinic – ABA Therapy Intake Form

Thank you for your interest in Shining Star Clinic – ABA Therapy Center.
Please complete this form as accurately as possible. Once we receive it, our team will contact you to review your information and discuss next steps.

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.

No Choosen File
(Max 10 MB)
No Choosen File
(Max 10 MB)
No Choosen File
(Max 10 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
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.
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.
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