Client Intake

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 Deer Park Drive
East Longmeadow, MA 01028
Fax: (413) 525-1900

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.

Child & Adolescent Intake Questionnaire

"*" indicates required fields

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Child/Adolescent Information

Child's name*
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Address*

Parent or Legal Guardian Information

Name*
Name

Health Care Insurance Information

Which of the following services would you like your child to receive (check all that apply):

Please check all that apply*
Is your child available for services before 2pm?*
Behaviors (check for yes)
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    ABOUT US

    Our mission is to improve the lives of individuals with developmental disabilities. We do this by offering individual programming that is geared towards the learner. Our belief is you are never too old to learn something new.

    RESOURCES

    • Autism Connections

    • Autism Society

    CONTACT

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    HOW TO FIND US

    55 Deer Park Drive, East Longmeadow, MA 01028

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