ABA Therapy Intake Form

Please carefully read and fill out the following form for ABA Therapy.

CHILD INTAKE FORM ABA

Child Intake Form for Behavior Therapy/ABA

Child's Information
Child's Name*
Gender*
Child's Current Age*
Date of Birth*
MM slash DD slash YYYY
Name of School
Grade*
Do You Have a Primary Care Physician?*
Primary Care Physician's Name
Primary Care Physician's Phone Number
Primary Care Physician's Address
Street Address Address Line 2 City State ZIP Code
Is your child currently being seen by a behavioral health technician?*
Describe your main concerns. Include when problems were first noticed, who noticed and where problems occur.*
Why are you seeking services for your child?*
Has your child’s physician noticed these concerns? If yes, what recommendations did he/she make?*
How did you learn about us?*
Are you currently utilizing any community resources (e.g. support groups, social groups, social services, school-based services or other social supports)?*
List all other services your child has received, including counseling; psychiatry; physical, speech, occupational or ABA therapy, etc. If none, skip..
Type of Service Dates/Ages Name of Provider

To list multiple services/providers, click the plus tab on the right to create another row.
Family Information
With whom does your child live? (Check all that apply.)*
- Biological parent(s)
- Adoptive parent(s)
- Grandparent(s)
- Legal guardian(s)
- Sibling(s)
- Other
List all family members who live with your child.*
Name Age Relation to the child

To add additional family members, click the plus tab to the right.
Please list family pets in the home. If none, skip.
Type Name

To add more than one pet, click the plus tab to the right.
Parent Information
Parent 1 Name*
First Last
Parent 1 Gender
Parent 1 DOB*
MM slash DD slash YYYY
Parent 1 Address*
Street Address Address Line 2 City State ZIP Code
Parent 1 Phone No. 1*
Parent 1 Phone No. 2
Parent 1 Email Address*
Enter Email Confirm Email
Parent 1 Preferred Method of Contact*
Parent 1 Employer*
Parent 1 Job Title*
Parent 2 Name
First Last
Parent 2 Gender
Parent 2 DOB
MM slash DD slash YYYY
Parent 2 Address
Street Address Address Line 2 City State ZIP Code
Parent 2 Email
Enter Email Confirm Email
Parent 2 Phone No. 1
Parent 2 Phone No. 2
Parent 2 Preferred Method of Contact
Parent 2 Place of Employment
Parent 2 Job Title
Are there family circumstances that would be helpful to share with your child’s therapist such as medical issues or legal issues? (e.g., custody arrangements)*
Are there any other languages spoken in the home? If yes, which language(s) and how often?*
Do any other family members any diagnosis or known medical conditions/ disorders? (e.g., ADHD, autism)
Relation to Child Related Condition/ Diagnosis?

To add more than one, click plus tab to the right.
Child's Health History
Describe your pregnancy, including any complications.*
Describe your labor/delivery, including any complications.*
Type of birth (check all that apply):*
- Spontaneous (not induced)
- Induced
- Vaginal
- C-section
Birth Place (hospital, etc.)*
Birth Attendant Name (physician, midwife, etc.)
Gestational Age (in weeks)*
Birth Length*
Birth Weight*
NICU?*
If your child stayed in the NICU, for how long?
Were there any complications after birth or during the first few weeks? (Check all that apply.)*
- Difficulty breathing
- Difficulty feeding
- Birth defect
- Jaundice
- Seizure
- Other
- None
Has your child's hearing been tested?*
If your child's hearing has been tested, when and where?
If your child's hearing has been tested, what was the determination?
Does your child have an infectious or communicable disease?*
If your child does have an infectious or communicable disease, please describe.
List any environmental or food allergies, please include adverse reactions to allergen.*
List any routine medications your child is currently taking or has taken long term.
Medication Doses Frequency Side Effects

To add more than one medication, click the plus tab to the right.
Describe any other conditions or diagnoses identified by your child’s doctor or other professionals.
Please list any spiritual or cultural variables that may impact treatment that we should be aware of.
Click all that apply.*
- Breastfed
- Formula Fed
- Both
If your child was breastfed, for how long? ( __ Months to __ Months.)
If your child was formula fed, for how long? ( __ Months to __ Months.)
At how many months-old did your child begin using a sippy cup? (If still not in use, skip.)
At how many months-old did your child begin using an open cup? (If still not in use, skip.)
At how many months-old did your child begin using a straw? (If still not in use, skip.)
At how many months-old did your child begin using utensils? (If still not in use, skip.)
Describe any difficulties with sucking, swallowing, chewing, eating different textures, etc.*
FAVORITE FOODS*
FOOD AVERSIONS*
Child's Educational Information
Name of School
Classroom Type
Teacher/Grade
School Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Does your child have an IEP?*
If yes, please provide us with a copy of the most recent IEP and ETR.
Child's Strengths and Favorites
Describe your child’s strongest skills and personality traits. What makes your child unique?*
FAVORITE ACTIVITIES / HOBBIES*
FAVORITE TOYS
FAVORITE MOVIES
FAVORITE BOOKS
Parent Electronic Signature*
First Middle Last
Today's Date*
MM slash DD slash YYYY

CHILD INTAKE FORM ABA

Child's Information

Family Information

Parent Information

Child's Health History

Child's Educational Information

Child's Strengths and Favorites

Let's Connect

Services

About Us

Type of Service	Dates/Ages	Name of Provider

Name	Age	Relation to the child

Type	Name

Relation to Child	Related Condition/ Diagnosis?