Comprehensive Intake and Consent Form

This intake form collects essential information for accessing autism services at the Minnesota Autism Center, including diagnostic evaluations and ABA therapy programs. The document requests:

Service preferences (diagnostics, ABA therapy options, family counseling)
Required documentation (IEPs, diagnostic assessments, school records)
Basic client information (name, DOB, gender, contact details)

Designed for applicants aged 18 months to 21 years, the form initiates the process for center-based or in-home ABA therapy while outlining the organization’s mission to support individuals with autism.

Note: All marked fields are required to prevent processing delays.

Minnesota Autism Center Intake Form 2

Client Information

Child’s Name

Middle Name

Last Name

Date of Birth

Referred by (if applicable)

Child’s Gender

Male

Female

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Legal Guardian Info

Guardian 1 Name

First Name

Middle Name

Last Name

Address Same as Patient?

Yes

Email 1

Phone 1

Cell Phone 1

Guardian 2 Name

First Name

Middle Name

Last Name

Relationship to Patient

Address Same as Patient?

Yes

Email 2

Phone 2

Cell Phone 2

Patient Insurance Information Form

Plan Type

Carrier Name

Plan Effective Date

Insurance Member ID

Policy Holder Information

First Name

Last Name

Policy Holder SSN

Policy Holder DOB*

Other Insurance Coverage

When there is dual coverage, Medicaid and Medicaid Managed Care policies are considered secondary plans.

Have you ever worked with a member services care manager at your current insurance provider?

Yes

Copy of Insurance Card/s

Front Side

Choose File

Back Side

Choose File

Acknowledgment

I understand that if I have missed my monthly premium payment and there has been a change in my coverage, I agree that I will be responsible for notifying the healthcare team immediately. I will also be responsible for paying all costs for any services rendered during the period in which there was a lack of insurance coverage.

Acknowledgment

It is the client's responsibility to reveal all insurances they have at the time of intake, as well as keep Heartend updated of changes in insurance along the course of treatment. In the event a member fails to inform of additional payers which may be liable for payment, it will be the member's responsibility to pay for such, including cost-sharing applied by primary payer.

Coordination of Care

Please list and provide contact info for all other providers in your child's life.

Patient Primary Care Physician Information

First Name

Phone/Mobile

Fax Number

Physician Office Email

Do you consent Heartland ABA to coordinate care with your child's PCP?

Yes

School Information

What school does your child attend?

School Location

Address Line

City

State

Zip Code

School Phone

School Contact Name and Position

Coordination Consent

Yes

Development History

Do you consent Heartland ABA to coordinate care with your child's Diagnosing Provider?

Yes

Do you have a Recent Evaluation?

Yes

Follow up date

Do you have a Recent IEP?

Yes

Do you have a prescription for ABA dated within the last 6 months?

Yes

Follow Up Date

Is your child seeing any specialist?

Yes

What previous therapy has your child received and how did he/she respond?

Please describe child’s milestone developments:

What goals would you like to address with ABA services?

What positive developments do you see in your child’s development?

What challenges do you face with your child?

What maladaptive behaviors does your child exhibit?

Is your children attending any educational day program? Please discribe

Services and Availability Details

I Understand

Parent Training should occur each week with your BCBA. In these sessions, you will collaborate to establish specific goals tailored to your child's needs. Together, you will address skill acquisition targets, develop strategies for reducing challenging behaviors, and learn how to effectively apply basic principles of ABA throughout the day with your child. Please check the box to indicate that you understand the importance of your participation in these sessions.

I Understand

When completing the initial assessment with your child's BCBA, they will recommend a dosage of direct treatment hours per week that best fit your child's needs. The BCBA recommendation is being made based on the level of care needed and amount of goals needed to be worked on. In order for our team to make an impact with your child, we require a schedule that meets the number of hours recommended by the BCBA. In addition, in order to maintain consistency and progress, we require that sessions timings will be followed and cancellations will be kept to a minimum. If a session is cancelled, please ensure to reschedule it with your care team.

I Understand

Our direct care services, delivered by our Behavior Technicians, will always be provided in person. Your child's BCBA will likely provide services through Telehealth. This model enables us to extend our quality care to your area.

Preferred BT Gender

Preferred BT Language

Weekdays

Monday

Tuesday

Wednesday

Thursday

Friday

Weekends

Saturday

Sunday

28. Names and ages of siblings if applicable

29. Names and relationship of any other individuals living in the home.

30. Emergency Contact #1 Name (required)

31. Emergency Contact #1 Phone Number (required)

32. Emergency Contact #2 Name (required)

33. Emergency Contact #2 Phone Number (required)

38. Hours Willing to Commit to ABA Therapy (required)

42. Height (inches) (required)

43. Weight (pounds) (required)

48: Client Diagnosis (required)

ASD - Level 1

ASD - Level 2

ASD - Level 3

ASD level unspecified

Rett’s Syndrome

Other Childhood Disintegrative Disorders

PDD Unspecified

Expressive Language Disorder

Mixed Receptive-Expressive Language Disorder

Speech and Language Development Delay

Global Development Delay

ADHD

Conduct Disorder

Down Syndrome

Trisomy 18/13

Other Trisomies

Schizophrenia

Anxiety Disorder, Unspecified

Major Depressive Disorder

Epilepsy

Cerebral Palsy

OCD

Oppositional Defiance Disorder

Behavior Concern

Fragile X

Bipolar Disorder

Intermittent Explosive Disorder

Pica

Phelan-McDermid Syndrome

Hard of Hearing

Selective Mutism

Separation Anxiety

Cortical Blindness

Dyslexia and Alexia

Other: Not Listed

49: Diagnosis Date (required)

50: Diagnosing Provider (required)

What challenges do you face with your child?

What maladaptive behaviors does your child exhibit?

Mankato Full Spectrum ABA Service Agreementand Consent to Treatment

This Service and Consent Agreement, made on

is between

and Mankato Full Spectrum ABA for Applied Behavior Analysis (ABA) services provided to

Mankato Full Spectrum agrees to provide all services as outlined in the Client Handbook.

I, the client or the client’s caregiver, have been given a document with all statements, policies, and procedures related to a therapeutic relationship with Mankato Full Spectrum in the Client Handbook.

These include, but are not limited to:

Healthcare laws and regulations
Patient rights regarding PHI
Client responsibilities
Complaints process
Company policies
Reasons for discharge

I, the client or client’s caregiver, have reviewed, understand, and agree to these statements, policies, and procedures as outlined by Mankato Full Spectrum.

I, the client or client’s caregiver, have had general ABA treatment and specific treatment for myself/my child explained to me in a manner in which I can understand (informed consent) by Mankato Full Spectrum. This includes descriptions of my/my child’s skills, deficits, goals, assessment techniques, treatment recommendations, and ABA practices.

I, the client or client’s caregiver, consent to the services and consent to

ABA treatment from Mankato Full Spectrum for

This Service and Consent Agreement shall remain in effect for one calendar year from the date above, the client is discharged from Mankato Full Spectrum, or until either party revokes this agreement in writing, whichever happens first.

Client or Caregiver’s Name

Client’s Name

Responsible Party's Name

Responsible Party's Signature

Date

Mankato Full Spectrum ABA Finacial Agreement

This Financial Agreement, made on this

is between

and Mankato Full Spectrum for Applied Behavior Analysis (ABA) services provided to

Client Insurance Information

Please attach a copy or a picture of the front and back of your insurance card.

Front

Choose File

Back

Choose File

Mankato Full Spectrum agrees to provide ABA services as outlined in the Client Handbook. I, the client's responsible party, agree to provide payment in the forms listed below:

Health Insurance Payment: I will provide Mankato Full Spectrum with all necessary information in order to bill my primary and secondary (if applicable) health insurance to cover costs of treatment.
Balance Billing: I will allow Mankato Full Spectrum to balance-bill any services not covered by insurance, as allowed by my specific health insurance plan. This may include copays, late fees, deductible payments, or other out-of-pocket expenses. Note: for Medical Assistance clients, balance billing is not allowed, so there are no other out-of-pocket costs for clients.

agree to these financial statements and enter into this financial agreement with Mankato Full Spectrum. This agreement will remain in effect until the client is discharged from Mankato Full Spectrum or from one year from today's date, whichever is soonest.

Responsible Party's Name

Responsible Party's Signature

Date

Minnesota Department of Human Services

EIDBI Rights & Responsibilities Acknowledgement - Form DHS-321720

➤ Click Here to Open Fillable PDF Form

How to Complete:

Fill out the form directly in your browser
Download the completed PDF to your device
Upload the saved file to our secure portal

Upload Your Completed Form:

Click Here to Upload

Purpose:
Documents your acknowledgment of rights and responsibilities as an EIDBI services participant or caregiver, per Minnesota Statutes.

I understand that ABA services are provided in accordance with the treatment plan developed by the supervising BCBA and team.

I consent to my child’s participation in ABA therapy and understand that therapy may take place in various settings (e.g., home, clinic, community)

I have received, reviewed, and agree to the Financial Agreement and understand I am responsible for any applicable co-payments, deductibles, or non-covered services.

I acknowledge that I have received and reviewed the HIPAA Privacy Practices Notice and understand my rights regarding privacy and confidentiality.

I consent to the use of data collection during sessions to support progress tracking and treatment plan adjustments.

I consent/do not consent (circle one) to photo/video recording for training, supervision, and clinical documentation purposes.

I agree to provide 24-hour notice for cancellations unless in cases of emergency. I understand that repeated missed appointments may result in discharge from services

I understand that if I have questions or concerns, I may contact the assigned BCBA or Mankato Full Spectrum ABA office at any time.

I authorize Mankato Full Spectrum ABA to communicate and exchange information with the
following individuals/entities (e.g., physician, school, case manager), for coordination of care
purposes:

Initial here to authorize release

Initial here to decline release

I certify that I have read and fully understand this Signature and Consent page. I certify that I am
either the client or the legal guardian authorized to sign on behalf of the client.

Client Name:

Client Date of Birth:

Parent/Guardian Name (if applicable)

Relationship to Client

Signature of Client/Guardian

Date

Comprehensive Intake and Consent Form

Client Information

Legal Guardian Info

Guardian 1 Name

Guardian 2 Name

Patient Insurance Information Form

Policy Holder Information

Copy of Insurance Card/s

Coordination of Care

Patient Primary Care Physician Information

School Information

Development History

Services and Availability Details

Mankato Full Spectrum ABA Service Agreementand Consent to Treatment

Mankato Full Spectrum ABA Finacial Agreement

Minnesota Department of Human Services

EIDBI Rights & Responsibilities Acknowledgement - Form DHS-321720

➤ Click Here to Open Fillable PDF Form

About Us:

Working Hours:

Get In Touch:

Personal Information

Background

Employment Eligibility

Employment Reference

Employment Reference

Employment Reference