NEW CLIENT | Happy Kiddos

New Client Form

Happy Kiddos Behavioral Services Corp. Application

INSTRUCTIONS: Answer each question accurately and completely.

Client First Name

Client Last Name

Phone

Caregiver Name

Date of Birth

Insurance

Select an Address

Diagnosis and when was the client diagnosed

Client is

Verbal

Non-verbal

Have the client received ABA before? If yes, then when was the last assessment or re-assessment done?

Place of service preferably for therapy? (Office, Home, Community and or School) If the answer is school, then is it a private or public school? Name of school and address.

If the answer is school then, what are his hours like in school?

Is the client receiving any other therapies such as Speech, OT, PT? If yes, then what are the scheduled hours?

To better serve you. Please upload the following documents for more information.

(We need uploaded the following)

Copy of Insurance

Upload File

Caregiver’s driver’s license

Upload File

Copy of Diagnosis

Upload File

Most recent referral for ABA

Upload File

Most recent assessment or re-assessment

Upload File

Copies of SRS2 or GARS3

Upload File

Privacy Notice

The information contained in your submission is confidential and intended solely for the use of the company (“Happy Kiddos Behavioral Services, Corp.”) The submission may contain individually identifiable information that must remain confidential and is protected by state and federal law.

Thank you for your submission - your new client services request has been submitted properly, please allow 1-2 weeks for our team to review the case and we'll contact you as soon as possible.