New Client Intake Form

Empowering Growth • Personalized Care • Maximizing Potential

At Autism Therapy Solutions, we are committed to providing compassionate, evidence-based therapy tailored to your child’s unique needs. Our Chicago-area team offers Applied Behavior Analysis (ABA), Speech Therapy, Occupational Therapy, and School Readiness programs in a welcoming and supportive environment. Each client receives an individualized plan developed and implemented by our dedicated clinical professionals.

Please complete the following information to begin the intake process. Note your information is secured through this page and will not be shared.

Client Name

Client DOB

Client Gender

Client Address

Does client have diagnosis?

Yes No

Parent #1 Name

Parent #1 Phone Number

Parent #1 Email

Parent #2 Name

Parent #2 Phone Number

Parent #2 Email

Insurance Subscriber

Child Parent

If parent is Subscriber, please provide parent's DOB

Insurance Carrier

Member ID

Group #

Have you previously met with either of the following of our leadership team?

Josh Ebert, Founder, MA, BCBA Rachel Meredith, Clinical Director, MA, BCBA Neither Both

If you havent met with both already, please list the days and times that work best for you to schedule a meeting.

How did you hear about us?