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New Client Intake Form
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Name
*
First
Last
Name of individual completing this form
What best describes your relationship to the client?
Parent/Guardian
Family/Friend
School/hospital & Third Party Referral Source
Current client referral
Other
Other, please specify
Email
*
Phone
What is the family's primary language?
English
Spanish
Somali
Other
If Other, please list family's primary language here (optional)
Interpreter required?
Yes
No
How did you hear about HIA's Doroteo Pediatric Center (optional)
Referred by medical professional
School
Direct Referral/Family
Web Search
Social Media
Other
List the name of the medical professional or direct referral/ family member.
Phone
Client Name
*
First
Last
Client's Date of Birth
Client's City of Residence
Parent/Primary Caregiver Name
*
First
Last
Primary/Caregiver Phone Number
Parent/Primary Caregiver Email
*
The client has a diagnostic assessment completed
Yes
No
Medicaid Insurance Provider
MN Medical Assistance (Straight MA)
MN Medical Assistance (PMAP) ex. Blue Plus, Ucare, Health Partner
Commercial Insurance
Private Pay
Other
Commercial Insurance Provider (private)
Blue Cross and Blue Shield of Minnesota (BCBSMN)
UCare
Health Partners
Private Pay
Other
Primary Insurance under MA or MinnesotaCare (Prepaid Medical Assistance Program (PMAP))
BluePlus
UCare
Health Partners
Medica
Other
Please list client's Medical Assistance (MA) policy number
Are you looking for a full or part-time ABA Program?
Full-time (40 hours)
Part-time (20 hours)
Is the client receiving or has the client received special services or accommodations at school, home or in the community?
Yes
No
If yes, please explain what type: (e.g. ITP, IEP, IFSP, 504 Plan)
Please list any diagnosis or behavioral concerns for your child
Phone
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