Intake Form

Client Information

Child Name *

Date of Birth

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Mother Name

Mother Date of Birth

Email Address

Phone

Are you the Primary Insurance MemberYesNo

Insurance Card

Drag and Drop (or) Choose Files

Father. Name

Father Date of Birth

Email Address

Phone

Are you the Primary Insurance MemberYesNo

Consent *

Confirm that the information provided is accurate and consent to its use.

To Call insurance on your behalf and also this is considered a consent to treat

Family Innovative Care is committed to ethical, high-quality ABA services built on consistency, preparation, and family partnership.

Located within Enchanted Tree House
Clinically supported by Innovative Behavior Solutions