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About Us
Services
Comprehensive Assessment
Clinic Based Therapy
In-Home and Community-Based ABA
Parent Training
Speech Therapy (Coming Soon)
ADOS-2 Testing (Coming Soon)
Careers
Contact Us
Getting Started
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Client Information/History
First Name
*
Last Name
*
Middle Initial
Address
*
Address Line 1
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Zip Code
Birthdate
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Gender
*
Male
Male
Female
Non-binary
Any Food Allergies? (If applicable)
Date of Diagnosis
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YYYY
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2015
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Who gave the Diagnosis?
*
Has your child ever received ABA therapy? If so, how long did they receive therapy?
Current Medications? (If applicable)
Does your child currently go to school or receive any current therapy? If so, please provide the schedule.
*
Special Diet/Restriction? (If applicable)
Describe eating or drinking patterns. Please indicate if your child can feed him or herself and what texture/types of foods he/she eats. Also list if bottles of sippy cups are used.
*
Describe sleeping patterns.
Describe toileting issues.
Next
Responsible Party Information
Parent/Guardian First Name
*
Parent/Guardian Last Name
*
Relationship to Patient:
*
Home Phone
*
Cell Phone
Work Phone
Work Phone Ext
Primary Email
*
Emergency Contact Name
*
Emergency Contact Number
*
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Next
Insurance Information
Does the child have more than 1 insurance coverage
*
Yes
No
Insurance Company
*
Secondary Insurance Company
*****Please make sure to upload all insurance cards****
Front of Insurance Card
*
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You can upload up to 5 files.
Allowed Multiple files
Back of Insurance Card
*
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Allowed Multiple files
Evaluation from specialist
*
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Allowed Multiple files
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Client profile
Please describe how your child communicates wants and needs. Also, describe your child’s conversation skills.
*
How does your child respond when he/she is told to do something (ex: throw this in the trash or clap your hands)?
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Does your child imitate moves you make? What about sounds? Can he or she imitate two different movements put together (ex: clap hands and then lift arms)?
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Can your child select items independently (ex: when told, “Go get your shoes,” he/she will return with both shoes)?
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What are your child’s greatest strengths?
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What areas of weakness would you like to see addressed?
*
Please add any other information about your child that would be helpful to know.
*
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What are your preferred dates and times for weekly Thrive Advanced Care services?
Monday
Start Time
End Time
Tuesday
Tuesday
Start Time
End Time
Wednsday
Wednesday
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End Time
Thursday
Thursday
Start Time
End Time
Friday
Friday
Start Time
End Time
Other
Other
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End Time
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