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Today’s Date (YYYY-MM-DD)
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Child’s Full Name
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Child’s Date of Birth (YYYY-MM-DD)
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Family’s Address
(required)
Parent/Guardian Full Name
(required)
Parent/Guardian Relationship to Child
(required)
Preferred Language
(required)
Cell Phone Number
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Home/ALT Number
Parent/Guardian Email
(required)
Is the child enrolled in school/preschool?
(required)
Yes
No
Availability (Select days and availability)
Monday – Fully Open
Monday – Not Available
Monday – Available for Certain Hours
Tuesday – Fully Open
Tuesday – Not Available
Tuesday – Available for Certain Hours
Wednesday – Fully Open
Wednesday – Not Available
Wednesday – Available for Certain Hours
Thursday – Fully Open
Thursday – Not Available
Thursday – Available for Certain Hours
Friday – Fully Open
Friday – Not Available
Friday – Available for Certain Hours
Saturday – Fully Open
Saturday – Not Available
Saturday – Available for Certain Hours
Insurance/Funding Source
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Member ID
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Upload Front & Back of Insurance Card
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Upload Psychological Evaluation or ABA Recommendation Form
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Current Diagnoses, Behaviors, and Areas of Concern
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How did you hear about us?
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General notes/comments
Intake Filled By
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Lightpath Staff
Family
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