Intake Questionnaire

Date: ______

Intake Questionnaire

Child’s Name: ______DOB ______

Address: ______

Mother’s Name: ______Phone ______

Email: ______

Father’s Name: ______Phone ______

Insurance Company: ______Insured under: ______

Policy Number: ______Member ID #: ______

How did you hear about us: ______

Medical Information:

Did you have a normal birth? If no, please explain. ______

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Please list any diagnoses your child has:______

Diagnosing provider:______Age of diagnosis: ______

Does your child have any allergies or medical conditions:______

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Does your child have any dietary restrictions:______

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Please list any medications, length of time on medication, reason for medication:

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Is your child currently receiving any other services (Speech, OT, etc.) and how often? ______

What grade is your child in? ______What school? ______

What type of classroom is your child attending? ______

Have you ever received ABA services before and if so, for how long? ______

Current Skill Level:

Communication:

Is your child’s main form of communication (gestures, words, sign language, augmentative communication device)? ______

How many words does your child typically use to request? ______

Does your child have 100 or more words they are able to use? ______

Does your child talk about items that are not present? ______

Please provide any other information you would like us to know about your child’s communication: ______

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Social skills:

Does you child independently interact with peers? ______

Describe your child’s current strengths socially: ______

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Describe your child’s current weakness socially: ______

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Please provide any other information you would like us to know about your child’s social skills.

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Self-Help Skills:

Is your child able to dress him or herself without help? ______

Is your child able to bath or shower independently? ______

Does your child have any issues with sleep? ______

Does your child have any issues with meal time or food variety? ______

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Please provide any other information you would like us to know about your child’s self-help skills.

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Problem Behaviors:

What events typically trigger problem behaviors? ______

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What do the behaviors typically look like: ______

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How long to these behaviors typically last? ______

How many times per week does your child typically engage in problem behaviors? ______

Does your child engage in any self-injurious behaviors? ______

Preferred items/Reinforcers:

Please list any items, activities or characters that your child enjoys: ______

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What skills or behaviors are most important to you and your family to target during services?

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Parent Signature: ______Date: ______