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Home
About
Services
Funding
News & Events
Blog
Employment
Contact

Enroll Today!

Home
About
Services
Funding
News & Events
Blog
Employment
Contact

Home
About
Services
Funding
News & Events
Blog
Employment
Contact

Enroll Today!

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Client Information
Client Information – Part 2
Parent or Legal Information
Parent or Legal Information – Part 2
Parent or Legal Information – Part 3
Funding Information
Reason for Service Need
School Information
Availability for Services
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Child’s Full Name*

Name

Primary Email*

Email Address

Date of Birth*

Select Date ×

Gender*

Female

Male

Siblings Name and Age

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Does Client Have a Current, Primary Diagnosis?*

If Yes, please indicate primary diagnosis name

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Name of Diagnosing Clinician (please include full name)*

Name

Name of Secondary Diagnosis (if applicable)

Name

Primary Language Spoken at Home*

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Current Treating Pediatrician*

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Address of Current Treating Pediatrician*

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Phone Number of Current Treating Pediatrician*

Phone

Name of Mother/Guardian #1*

Mobile Phone Number*

Phone

Home Phone Number

Phone

Mother/Guardian #1 Email Address*

Email Address

Mother/Guardian #1 Home Address*

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Name of Father/Guardian #2

Name

Mobile Phone Number

Phone

Home Phone Number

Phone

Father/Guardian #2 Email Address

Email Address

Father/Guardian #2 Home Address

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Parents are*

Married

Separated*

Divorced*

Single*

Child is*

Biological Child

Adoptive Child

Foster Child

If client is under 18, who has custody of the minor?

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Do you have access to the internet?*

Yes

Preferred Method of Communication for parents/guardians:*

Phone

I have the following funding source:*

Private Pay

Regional Center

Insurance

School District

Other

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Please provide name of the Regional Center (RC), Insurance, School District, or person paying for the service*

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Does your current Insurance Plan cover ABA services?*

Yes

I don’t know

What type of services are you interested in right now? (check all that apply)*

In-Home ABA/Behavior Therapy

Parent Training

Teacher Training

School Observations/Assessments

Assessment of Problem Behaviors and/or Skills

Social Skills/Play Groups

Toilet Training

Bedtime/Sleep Training

Feeding Programs

School Behavior Support

List Problem Behaviors*

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Select Current Areas of Concern*

Language

Play

Social Skills

Adaptive

Academic

Self-Management Skills

Motor Skills

Any other reason(s) for service?

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Is your child currently in school?*

Yes, Name of School

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School Address

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Please enter the days your child attends school and list the school times for each day.

	School Times
	School Times
Mondays	School Times
Tuesdays	School Times
Wednesdays	School Times
Thursdays	School Times
Fridays	School Times

Does your child nap?*

Yes, When are his/her nap times

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When is your child available for services? Please select all that apply:

	8:00am-12pm	12:00-3:00pm	3:00-6:00pm
	8:00am-12pm	12:00-3:00pm	3:00-6:00pm
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays

	8 am-11am	11am-2pm
	8 am-11am	11am-2pm
Saturdays

How did you hear about Behavior Trend?*

Website

Friend

Regional Center

Facebook

School

Other

Write here

For married couples and for guardians who have joint/shared legal custody, both parents must sign and return this form. For legal guardians who have sole legal custody, you must attach your Child Custody Order indicating yourself as the sole legal guardian of the minor named on this form. By signing below, I affirm that all the information on this form is the most accurate and updated information to the best of my knowledge.

Parent/Legal Guardian #1 Name*

Name

Parent/Legal Guardian #1 Signature

Parent/Legal Guardian #2 Name

Name

Parent/Legal Guardian #2 Signature

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Behavior Trend, Inc. provides Applied Behavior Analysis services to clients in various settings, parent and teacher training, and school services.

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Tel: 818.369.4440
Fax: 818.369.5800
Info@BehaviorTrend.com

15315 Magnolia Blvd. Suite 426

Sherman Oaks, CA 91403

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DISCLAIMER:

Behavior Trend is a registered trademark of Behavior Trend, Inc.

Disclaimer: The material provided on this site is for informational and educational purposes only and is subject to change without notice. The information presented here does not reflect the opinions or recommendations of any past or present affiliates. The material provided on this website should not be used to diagnose or treat any condition or disorder. The information provided here is not to be used as medical or legal advice. Please refer to your licensed pediatricians, psychologists, psychiatrists, and other professionals who work with your child’s health and advocacy needs.