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 InformationChild's Name* Gender*MaleFemaleChild's Current Age* Date of Birth* MM slash DD slash YYYY Name of School Grade*No School YetPre-KKindergarten123456789101112Trade School/Post-SecondaryDo You Have a Primary Care Physician?*YesNoPrimary Care Physician's Name Primary Care Physician's Phone NumberPrimary Care Physician's Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your child currently being seen by a behavioral health technician?*YesNoDescribe 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 ServiceDates/AgesName of Provider To list multiple services/providers, click the plus tab on the right to create another row. Family InformationWith 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.*NameAgeRelation 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.TypeName To add more than one pet, click the plus tab to the right. Parent InformationParent 1 Name* First Last Parent 1 GenderMaleFemaleParent 1 DOB* MM slash DD slash YYYY Parent 1 Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent 1 Phone No. 1*Parent 1 Phone No. 2Parent 1 Email Address* Enter Email Confirm Email Parent 1 Preferred Method of Contact*Phone No. 1Phone No. 2EmailParent 1 Employer* Parent 1 Job Title* Parent 2 Name First Last Parent 2 GenderMaleFemaleParent 2 DOB MM slash DD slash YYYY Parent 2 Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent 2 Email Enter Email Confirm Email Parent 2 Phone No. 1Parent 2 Phone No. 2Parent 2 Preferred Method of ContactPhone No. 1Phone No. 2EmailParent 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 ChildRelated Condition/ Diagnosis? To add more than one, click plus tab to the right. Child's Health HistoryDescribe 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?*YesNoIf 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?*YesNoIf your child's hearing has been tested, when and where? If your child's hearing has been tested, what was the determination?PassDid not passSeeking a follow-upDoes your child have an infectious or communicable disease?*YesNoUnsureIf 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.MedicationDosesFrequencySide 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 InformationName of School Classroom Type Teacher/Grade School Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Does your child have an IEP?*YesNoIf yes, please provide us with a copy of the most recent IEP and ETR. Child's Strengths and FavoritesDescribe your child’s strongest skills and personality traits. What makes your child unique?*FAVORITE ACTIVITIES / HOBBIES*FAVORITE TOYSFAVORITE MOVIESFAVORITE BOOKSParent Electronic Signature* First Middle Last Today's Date* MM slash DD slash YYYY Δ