Mankato Full Spectrum ABA

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


Legal Guardian Info


Guardian 1 Name
Guardian 2 Name

Patient Insurance Information Form


Policy Holder Information

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

Copy of Insurance Card/s

Coordination of Care

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


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 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

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.

Mankato Full Spectrum ABA Finacial Agreement


Client Insurance Information

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

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:

  1. 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.

  2. 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.

Minnesota Department of Human Services


EIDBI Rights & Responsibilities Acknowledgement - Form DHS-321720

 

➤ Click Here to Open Fillable PDF Form

 

How to Complete:

  1. Fill out the form directly in your browser

  2. Download the completed PDF to your device

  3. Upload the saved file to our secure portal


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

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:

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.