Client Intake Questionnaire

Thank you for your interest in Assent Academy. Please complete this questionnaire so our team can learn about your child's needs, confirm potential schedule alignment, and discuss next steps. It takes about 10 minutes. Questions marked * are required.

Your privacy matters. We only ask for what we need to understand fit and scheduling. Detailed insurance numbers and clinical records are collected securely later in the intake process, not through this form.

Child & Guardian Information

Child's Full Name

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Date of Birth

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Age

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Parent/Guardian Name(s)

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Phone Number

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Home Address

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Clinical Eligibility & Required Documentation

This helps our team understand documentation needs for an initial evaluation and service planning. Requirements can vary by insurer — we'll confirm with you.

Does your child have a formal medical diagnosis of Autism Spectrum Disorder (ASD)?

Yes No

Please choose an option.

Do you have a Diagnostic Evaluation Report / Comprehensive Diagnostic Assessment on file?

Yes No

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Do you have a current doctor's referral/prescription for ABA therapy from your pediatrician?

Yes No

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Insurance & Funding

Please share the plan name only. We'll collect policy, subscriber and group numbers securely when we connect with you — never send them by email.

Primary Health Insurance Provider (optional)

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Is your child covered under a secondary insurance policy or Medicaid? (optional)

Yes No

Provider name

Please add details.

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Schedule Availability & Commitment

ABA schedules vary by individual needs, clinical recommendations, availability and insurance authorization. Evening times are often in high demand; flexible morning or early-afternoon availability may offer more options.

How many hours per week of ABA therapy are you seeking for your child?

10–15 hours/week 15–25 hours/week 25–35+ hours/week

Please choose an option.

Where are you seeking services?

In-Home only School/Community-based (if available) Combination of available settings

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Philosophy & Family Expectations

Assent Academy practices neuro-affirming and assent-based care. We prioritize building a safe, trusting relationship with your child, respecting verbal and nonverbal "no," honoring sensory needs, and working alongside the learner rather than forcing rigid compliance.

Top goal #1 for your child in ABA therapy

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Goal #2 (optional)

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Goal #3 (optional)

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Are you able to participate in caregiver training / collaboration sessions (for example, one hour biweekly or monthly, as agreed with your team)?

Yes No

Please choose an option.

Availability	Mon	Tue	Wed	Thu	Fri	Sat
Morning: 8 AM–12 PM
Early Afternoon: 12 PM–3 PM
Evening: 3 PM–7 PM

Client Intake

Child & Guardian Information

Clinical Eligibility & Required Documentation

Insurance & Funding

Schedule Availability & Commitment

Current Supports & Communication Profile

Philosophy & Family Expectations

Ready to Take the Next Step?