Free Consultation — A Gifted Journey

This form typically takes 5-10 minutes to complete. All information is kept confidential. If you have questions, call us at (972) 379-9131.

Parent / Guardian Information

Parent/Guardian Full Name *

Relationship to Child *

Phone Number *

Email Address *

Home Address *

City, State, Zip *

Preferred Contact Method

Secondary Contact Name & Phone (emergency)

Child Information

Child's Full Name *

Date of Birth *

Age

Gender

Primary Language Spoken at Home

Diagnosis & Medical History

Has your child been diagnosed with ASD? *

Date of Diagnosis (if applicable)

Diagnosing Physician / Clinic

Other Diagnoses (check all that apply)

Current Medications

Allergies

Primary Care Physician

Behavioral & Developmental Information

Has your child received ABA therapy before? *

Other therapies your child currently receives

How does your child primarily communicate?

Describe your primary behavioral concerns

What are your top 3 goals for your child?

What are your child's strengths and interests?

Education & School

Current School / Program

Grade / Classroom Type

Does your child have an IEP or 504 plan?

Insurance Information

Insurance Provider *

Member / Policy ID

Group Number

Subscriber Name

Secondary Insurance (if applicable)

Scheduling & Referral

Preferred Session Times *

Preferred Therapy Location *

How did you hear about A Gifted Journey?

Anything else you'd like us to know?

By submitting, you agree to be contacted by A Gifted Journey regarding ABA therapy services.

Client Intake Form

Your Child's Gifted Journey Starts Today