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Blooming Butterflies Therapy LLC 
 Intake Form

Client Information

Birthday
Month
Day
Year

Recommended for Authorization

Autism Diagnosis
Yes
No

Guardian Information

Multi-line address

Additional Information

Provider Preference

Important Documents

Your Privacy Matters

At Blooming Butterflies Therapy LLC, we take the protection of your family's information very seriously. Your privacy is important to us. Any personal, medical, or behavioral health information you provide in this form is protected under the Health Insurance Portability and Accountability Act (HIPAA) and will be used solely for the purpose of evaluating your child's/client's needs and coordinating care. Information submitted here is transmitted securely and will only be accessed by authorized clinical and administrative staff involved in your care. We do not sell, share, or disclose your information to third parties except as required for treatment, billing, or as permitted or required by law

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