Child & Adolescent Intake Questionnaire

The following questionnaire is to be completed by the child’s parent or legal guardian. This form has been designed to provide essential information so we can provide the best services for your child. Please feel free to add any additional information, which may be helpful in understanding your child.

Requirements to be added/remain on our wait list for ABA services:
1. Complete the Child & Adolescent Intake Questionnaire
2. Include a copy of the following paperwork:

  • Report of initial Autism diagnosis
  • Most recent physical records
  • Referral from pediatrician to request ABA services
  • Copy of insurance cards
  • Current IEP or 504 Plan (if school age and in place)

Please submit the Child & Adolescent Intake Questionnaire by completing the form below or print and fill out the form and
return via mail, fax, or in person.

Embracing The Creative Child
55 Dear Park Drive
East Longmeadow, MA 01028
Fax: (413) 525-1900

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