Abbreviated Application for Behavioral Services
Date:______
Child’s Name: ______Date of Birth: ______
Diagnosis: ______Evaluator who made diagnosis: ______Date of Dx: ______
*Please provide a copy of the report
Parent/Guardian 1 Name: ______
Relationship to Child: ______
Parent/Guardian 1 Education: ______
Parent/Guardian 1 Occupation: ______
Parent/Guardian 2 Name: ______
Relationship to Child: ______
Parent/Guardian 2 Education: ______
Parent/Guardian 2 Occupation: ______
Health Insurance Information: ______
Subscriber Name: ______SubscriberDate of Birth: ______
Insurance: ______
Identification Number: ______
Group Number: ______
Subscriber’s Employer: ______
Home Address: ______
______
Contact Information: home phone: ______work: ______
email: ______mobile:______
Siblings/Ages: ______
______
Caretakers: ______
Other people living in the home: ______
What language is spoken in the home? ______
Chief Problem or concern: ______
______
______
What do you hope to gain from this consultation? ______
______
Current School Placement
Present Grade: ______Has your child repeated a grade? ______
Name of School: ______
School Address: ______
School Contact Person: ______
Teacher: ______Phone Number: ______
Teacher assistant or one-to-aide: ______
ABA (Applied Behavior Analysis) Instructor or Behavior Therapist: ______
Behavior Analyst or Specialist: ______
Number of hours of ABA per week: ______Number of hours of consultation per week:______
Occupational Therapy Services (per week): ______
Physical Therapy Services (per week):______
Speech Language Services (per week): ______
Communication
How does your child communicate? ______
______
Play Skills
How does your child play? ______
______
Daily Routine
Please describe your child’s regular schedule (including naps):
Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday7:00-8:00
8:00-9:00
9:00-10:00
10:00-11:00
11:00-12:00
12:00-1:00
1:00-2:00
2:00-3:00
3:00-4:00
4:00-5:00
5:00-6:00
6:00-7:00
7:00-8:00
Self Help Skills
Eating: ______
Dressing: ______
Bathing: ______
Toileting: ______
Behavior
Aggression: ______
Stereotypy (any repetitive movement without apparent purpose): ______
______
Self Injurious Behavior: ______
Other Maladaptive Behavior: ______
______
______
Has your child ever received psychotherapy or counseling? ______
If yes, why? ______
Have you ever worked with a behavioral consultant? ______
If yes, please give the name(s) of the consultants: ______
______
Please describe the child’s strengths: ______
______
______
Please describe the child’s weaknesses: ______
______
______
Is your child on any medication? (Please list including name, dosage, and prescribing physician):______
Developmental History
Pregnancy: ______
______
Infancy: ______
______
Feeding Problems? ______
Sleeping Problems? ______
Developmental Milestones
Sat at age: ______Walked at age: ______
Smiled at age: ______Spoke in two-word phrases at age: ______
Child’s Health
Please describe the child’s general health: ______
Name of Primary Care Physician: ______
Address of Primary Care Physician: ______
Phone Number of Primary Care Physician: ______
Date of child’s last physical:______
Please include copy of results/proof of physical
Please describe the parent’s general health: ______
Does your child have any specific medical problems? ______
______
Serious Illness? ______
History of seizures/convulsions? ______
Operations? ______
Other Hospitalizations? ______
Allergies (Including reactions and treatment)?______
Sensitivities? ______
Ear Infections? ______
Visual Problems? ______
Diet Restrictions? ______
______
Signature Date
Please feel free to note any other concerns below:
______
______
______
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