Confidential Client Information
Please fill out the form below to start your intake process. Once we receive this form, we will begin to verify your insurance information and will contact you via email to gain more information about your child and which of our services are of interest to you.

We do our best to ensure that the insurance benefits we relay to you are correct. However, Spectrum of Hope is not responsible for any errors or omissions conveyed to us by your insurance carrier. PLEASE BE AWARE THAT INFORMATION WE RELAY FROM YOUR INSURANCE COMPANY DOES NOT GUARANTEE COVERAGE.

NOTICE: Medicare/Medicaid does NOT cover ABA services in the state of Texas.
AVISO: Medicare/Medicaid NO cubre los servicios de ABA en el estadio de Texas.
Client Information

* Indicates required field
Client's Name

Date of Birth *

Gender *

How did you hear about us? *

If you chose "doctor" or "other" please let us know who it was *
Diagnosis (Please enter all that apply to receive the most accurate insurance information)
Family Information

Parent/Guardian 1

Relationship to client *

Parent/Guardian 1 Email

Parent/Guardian 1 Phone

Parent/Guardian 1 Address

Parent/Guardian 2

Relationship to client *

Parent/Guardian 2 Email

Parent/Guardian 2 Phone

Parent/Guardian 2 Address

Primary Contact *
Service Request - Click all that apply

Behavior Treatment Services Needed

If you chose Part Time, please list preferred hours
Current Placement / Services

If you chose "other", please tell us about your child's current placement
Insurance Information

Insurance Company*

Insurance Company Address

Insurance Company Phone Number *

Name of Insured*

Relationship to Client*

Insured Date of Birth*

Member ID*

Group Number

Group Name