Patient Intake Form

Name*

First Last

Medicaid #

Sex*

Phone*

Email*

Please provide contact main e-mail for parent/guardian for Sanger and Associates to reach out to.

Date of Birth:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent/Guardian’s Name(s)

First Last

Address

If different from patient

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

If different than patient

School

If attends

Teacher at school

Referral Information

Referring Physician/Person referring patient for services

Diagnosis

Reason for Referral

Is client verbal?

Yes
No

If so, what language?

Pediatrician/Family Doctor

First Last

Phone

Schedule Desired

Please list the days you are available for behavior services on each day.

Monday
Tuesday
Wednesday
Thursday
Friday
Weekends

Appointment Time Preference

To better organize appointment, please choose a preferred time for your appointment.

Mornings
Early Afternoons
Late Afternoons

Behavior Information

Please list behavior problems you are concerned about (tantrums, aggression, etc.) as well as how often the behavior is occurring.

Skill Deficits

Please list skill deficits you are concerned about (language, fine motor, potty training, etc.) that you would like to see addressed in therapy.

Forms of Communication

Is child vocal?*

Yes
No

If so, does he/she have delays with communication?

Yes
No

If there are delays, approximately how many words does he/she use?

Does he/she use sentences?

Yes
No

Does he/she request things using words?

Yes
No

Does he/she request things using signs or pictures?

Yes
No

If there is no form of communication at home (vocal language, signs, or pictures) how does your son or daughter request items he/she wants?

Please list any additional information you would like to share with us regarding your child at this time

Necessary Information

Parents: You must have your child’s referring physician provide you with a referral for ABA therapy with a diagnosis on the referral. You also must have either an IEP or an Evaluation from a Developmental Pediatrician.

What type of Medicaid

CAPTCHA

Please fill out form below. Your submission will be securely sent to us. We will reach out within 3 business days.

Referral Information

Forms of Communication

Necessary Information

Would rather print and fax this intake form?