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Clinical Services Intake Form

Hello, this form is the first step in the intake process for services at Brightside ABA Services. Upon receipt and review of the form, we will follow up with you to schedule a time to meet virtually to discuss your family’s needs in more detail and review the next steps.

Please contact us with any questions or concerns.

The completed form will automatically be made available to our Registered Behaviour Analysts, Occupational Therapists and/or Speech Language Pathologists.

First Name*

Last Name*

Email Address*

Phone*

Do you require a translator?* Do you require a translator?* Yes No

You answered 'Yes' to needing a translator. Please indicate for which language.

Do you Reside in Waterloo Region?* Do you Reside in Waterloo Region?* Yes No

You answered 'No' to the above question. Please indicate where you reside?

Are you currently receiving Access OAP funding?* Are you currently receiving Access OAP funding?* Yes No, I am not eligible Waiting on my funding No, I will be purchasing with insurance or privately

If applicable, what is your OAP number?

Are you currently receiving services from another provider? If so, select the provider. Are you currently receiving services from another provider? If so, select the provider. ABA OT SLP

What is your child's First and Last Name*

Age of Child/Youth/Adult* Age of Child/Youth/Adult* Under 4 4-6 7-9 10-12 13-15 16-18 Over 18

What type of Clinical Services are you interested in? (check all that apply)* What type of Clinical Services are you interested in? (check all that apply)* Applied Behaviour Analysis (ABA) Occupational Therapy (OT) Speech-Language Pathology (SLP) I am unsure and would like support determining which service may be the best fit

Does the child/youth/adult engage in any of the following? (choose all that apply)* Does the child/youth/adult engage in any of the following? (choose all that apply)* Self-harm Harm to others (kicking, hitting, biting, etc.) Action to objects (throwing, etc.) Yelling/Screaming Inappropriate sexual behaviour Elopement Property destruction None of the above

What are the top 3 goals you are hoping to work on? If you are unsure, please share the main concerns or areas where support is needed. What are the top 3 goals you are hoping to work on? If you are unsure, please share the main concerns or areas where support is needed. What are the top 3 goals you are hoping to work on

Goal #1

Goal #2

Goal #3

If you move ahead with services, what time of day do you desire for service to be delivered? (choose all that apply) Note: we do not offer weekend services* If you move ahead with services, what time of day do you desire for service to be delivered? (choose all that apply) Note: we do not offer weekend services* Morning (8:30 - 12:00) Afternoon (12:00 - 5:00) Evening (5:00-7:00) *Note: there may be additional delay in receiving services due to limited availability

Where do you desire services to be delivered? (check all that apply)* Where do you desire services to be delivered? (check all that apply)* In-Home Our Centre Virtual

When would be a good time to contact you? (choose all that apply)* When would be a good time to contact you? (choose all that apply)* Morning Afternoon Evening

What would be the best way to contact you? (choose all that apply)* What would be the best way to contact you? (choose all that apply)* Email Phone

How did you hear about us at Brightside ABA Services?*

Do you provide consent to be added to our newsletter. We use the newsletter to inform families of upcoming service offerings and opportunities. Do you provide consent to be added to our newsletter. We use the newsletter to inform families of upcoming service offerings and opportunities. Yes No