Confidential Client Intake

Welcome to Spectrum of Grace

Please complete this intake questionnaire so our clinical and educational directors can review your child's unique needs, verify any insurance benefits, and prepare for your first consultation.

Confidential & HIPAA-Minded Reviewed Within 24–48 Hours No Obligation

1. Parent / Guardian Information

Primary contact responsible for communication & scheduling

First Name *

Last Name *

Relationship *

Primary Phone *

Email Address *

Street Address

City

State

Zip

2. Child's Information

Tell us about your child so we can tailor clinical & academic pacing

Child's First Name *

Child's Last Name *

Date of Birth *

Gender *

Diagnosis (or Suspected Needs) *

3. Program of Interest & Availability

Select pathway & schedule

Program of Interest *

Preferred Schedule / Availability

4. Insurance & Funding Information

We verify ABA benefits at no charge so you know exact coverage

Payment Method *

Insurance Provider

Member / Policy ID

Group Number

Subscriber Name

5. Goals & Developmental Profile

What matters most right now?

Primary Concerns & Goals

Previous Therapies

Child's Strengths & Joy

SMS Communication Opt-In (Optional): I consent to receive text messages from Spectrum of Grace ABA Clinic & Academy regarding intake status, tour scheduling, appointment reminders, and enrollment updates at the phone number provided above. Message frequency varies. Message & data rates may apply. Reply STOP at any time to unsubscribe, or HELP for assistance.

Consent is not a condition of receiving services. See our Privacy Policy and Terms of Service. We never sell or share personal data with third parties for marketing.

Questions? Call (469) 900-8063

Direct to Our BCBA

Forms are delivered directly to clinical leadership for prompt, thoughtful review.

Insurance Verification

We handle verification with your insurance carrier at zero cost to your family.

Carrollton Center

Located at 4425 Plano Pkwy, Suite 501, Carrollton, TX 75010, convenient to North Dallas, Plano & Frisco.