Hello, and welcome to Spectrum ABA's electronic intake packet.  Please take the time to answer as many questions as you can as the information in this packet will help our team best serve the client.  If you have questions or need assistance, please email admin@spectrum-aba.com.

Note: In the form you will be able to upload copies of your insurance card(s) and your diagnosis paperwork.  If you do not have these at this time, you can upload separately, but it is preferred to attach with the packet if possible.

Important: Please list all available service times below.  The more availability the client has could help reduce wait list time.  Please be as accurate as possible and check ALL of the hours for each day of the week that you have available.  If the client availability splits an hour, go ahead and check the box.  For example, if availability starts at 9:00am, check the 8:30-9:30am box.

Note:  Sessions must be a minimum of 3 hours in length, with a minimum of 15 hours per week of ABA therapy.

If Yes, complete the rest of this section.  If not, please skip to next page.

Below you can attach copies of different assessments and evaluations.  If you do not have the files accessible at this time, you can e-mail copies to admin@spectrum-aba.com.

I hereby certify that the above statements and information are true and correct to the best of my knowledge and understand all information in this packet will become part of the client's file.