An ABA intake form helps a pediatric therapy clinic collect family details, history, goals and preferences before a first visit. This guide shows fictional ABA, occupational therapy and speech therapy intake fields and explains questions to ask about consent and online forms.
Fictional example only. Adapt these samples to your clinic’s own policy and professional judgment. This is not clinical, legal or regulatory advice and does not claim to meet any payer, regulator or certification-body requirement. Have your own counsel review consent wording, especially for minors and shared custody.
A client intake form gathers the family details, referral or service history, goals, communication needs and preferences a clinic needs to prepare for a first visit. A pediatric therapy intake form may also ask who should receive scheduling messages and which questions the family wants to discuss. The clinic decides which fields it needs and who may access them.
These sample fields are prompts for a clinic’s own form design. They contain no real client information or required clinical questions.
An ABA clinic can ask about communication, routines and family priorities without treating a completed form as an assessment. Client F and all entries below are invented.
| Sample field | Fictional answer |
|---|---|
| Caregiver relationship | Parent |
| Preferred contact method | Secure portal message |
| Current communication | Uses words and picture choices |
| Family priority | Discuss transitions between activities |
| Visit preference | Ask about a quieter waiting space |
Fictional fields and answers; the supervising clinician chooses real intake questions.
An occupational therapy intake form can give a clinician context about daily activities and family questions before an evaluation. These are fictional prompts, not a screening tool.
| Sample field | Fictional answer |
|---|---|
| Daily activity to discuss | Getting ready for school |
| Family observation | Prefers drawing at a table |
| Setting preference | Ask about room setup |
| Family goal | Discuss participation in morning routines |
Fictional entries do not suggest a diagnosis or intervention.
A speech therapy intake form can ask about languages used at home, communication history and the family’s goals. The clinician decides what follow-up questions are appropriate.
| Sample field | Fictional answer |
|---|---|
| Languages used at home | English and another family language |
| Communication preference | Give time to answer questions |
| History to discuss | Prior school-based support |
| Family goal | Discuss communication during play |
Fictional entries are a layout example, not clinical advice.
A treatment consent form or ABA consent form usually describes the proposed service, who is being asked to consent, how information may be shared and the clinic’s cancellation terms. A clinic may also explain the questions a family can raise before signing. A therapy consent form needs wording tailored to the clinic, service and people involved.
For minors and shared custody, do not assume one generic form settles who can consent or receive information. Have counsel review the clinic’s wording and process, and confirm current requirements with the relevant professional body. The sample intake tables are not consent language.
An electronic consent form lets a family review the clinic’s text online. For an e-signature consent form, ask whether the record shows the version agreed to, who signed and when. Keep the signed document with the client record under the clinic’s own policy.
Electronic consent forms do not remove the need to answer questions or review wording. This guide does not say that an electronic signature is legally sufficient for any particular service or person.
A clinic can send online intake forms and consent forms online through a portal before a visit, then review responses under its own workflow. Confirm what families can see, who follows up on missing answers and how corrected forms are handled.
TherapyCRM sends forms through the parent portal, supports e-signature for clinical documents and keeps signed documents on the client record. The Family portal, ABA practice and therapy progress pages describe related workflows. TherapyCRM serves English-language practices in Canada outside Quebec. It is practice management software with a clinical record, not a physician EMR, and has no EMR certification. It has no telehealth or video visits and does not submit insurance or government claims, including Ontario Autism Program claims.
It gathers family details, relevant history, goals, preferences and contact information before a first visit. A clinic chooses the fields needed for its own service.
It may ask about communication, routines, family priorities and visit preferences. The fictional ABA table shows sample fields, not an assessment or required questionnaire.
An OT form may ask about daily activities and participation; a speech therapy form may ask about communication history and languages used at home. Clinicians decide the appropriate follow-up.
It usually explains the proposed service, who is asked to consent, information sharing and cancellation terms. Counsel should review the clinic’s wording, especially for minors and shared custody.
A clinic should be able to show what version was agreed to, who signed and when. This guide does not claim an e-signature is legally sufficient in a particular situation.
Yes. Families can complete forms through the parent portal. TherapyCRM supports e-signature for clinical documents and keeps signed documents on the client record.