The Sunshine Academy Intake Form

Child's First Name

Child's Last Name

Child's DOB

Child's Primary Insurance

Child's Secondary Insurance

Upload Image of Insurance Card(s):

Upload Image of Insurance Card(s)

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Email

Parent/Guardian Cell Phone

Does Child have Autism Diagnosis?

Yes

No

Child's Current School

Upload the Autism Diagnosis REPORT:

School Category:

Special Ed.

General Ed.

What ABA therapy schedule are you hoping for, assuming insurance approves?

Are you seeking full-time or part-time ABA therapy for your child?

Or, you can also explain your ABA therapy schedule needs here:

Additional Therapy Services Currently Receiving:

Speech Therapy

Occupational Therapy

Where are they attending for additional therapy services?

If your child has attended ABA therapy elsewhere, list ABA provider name:

Is there anything else you would like to tell us about your child that you feel might be helpful?

I agree to receive emails, calls, or texts from The Sunshine Academy about ABA services, updates, and resources. I understand I can opt out at any time.

I consent to the collection and use of the information provided in this form for the purpose of contacting me about ABA services for my child.

I acknowledge that the information provided may include protected health information (PHI) and consent to its use for initial evaluation and service coordination, as protected under HIPAA.

Have any Questions?????

Call or text 918-900-6237