Child and Adolescent Intake Questionnaire

Demographic Information:

Name of person/caregiver providing information

Legal name of child/adolescent *

Nickname

Child's Date of Birth *

Primary Address *

Primary Caregiver's Phone Number *

Primary Caregiver's Email Address *

Days/hours to best reach the primary caregiver *

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Caregiver's preferred method of communication *

Phone

Email

Text

Any

Caregiver's preferred method of Instruction *

Written

Hands-on

Visual(e.g.,Video)

Others

Describe here

Name of School *

County

School Telephone

Current grade *

School Contact Person *

Current Teacher(s) *

Classroom setting *

General Education

Autism Classroom

Others

Please list any cultural preferences that may impact treatment

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How did you hear about Allium Behavioral Services?

Medical Insurance Information

Kindly upload a copy of the child's health insurance card *

Name of Insurance Company *

Name of policy holder *

Date of Birth of Policyholder *

Insurance address *

Phone number

Member I.D *

Group I.D *

Parent Information

If divorced, who has physical custody?

If divorced, who has legal custody?

If divorced, upload a copy of the custody agreement

Mother's name *

Father's name *

Mother's Date of birth *

Father's Date of Birth *

Mother's Employer *

Father's Employer *

Mother's Occupation *

Father's Occupation *

If divorced, how long has the biological parents been divorced?

Has either parents been married before or since? *

Please list the names of Step Parents

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3

Is there a birth parent living outside of the home? *

Yes

No

Please list all siblings, age and relationship

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4

Are all siblings living in the home?

Are there any other language(s) other than English spoken in the home? *

If yes, please list

Language 1
Language 2
Language 3

Are there any other people who play a significant role in how this child is raised? *

If yes please list:

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3

Please list any spiritual variables that may impact treatment including family religious practices and learning preferences *

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3

Please list any cultural variables that may impact treatment including but not limited to dietary needs, accommodations, practices, and learning preferences *

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3

Psychological History

Please list the following information from previous evaluations for the child you are seeking services: Place of evaluation, Doctor, Diagnosis and Date *

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Therapy History

Please list the following information about therapies your child has previously received: Therapy, Provider, Start/End dates, Focus *

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5

Family History

Please describe any immediate family history of Autism Spectrum Disorder *

Please describe any immediate family history of Mental Health Disorder *

Current Therapies

Please list the following information about therapies your child is currently receiving: Therapy, provider, Start/end dates, Focus. *

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5

Has your child received Applied Behavior Analytic Services before? *

If yes, which agency(ies)

If your child has received ABA services before, did the child make progress? *

If yes, what areas? *

Pre-Natal and Delivery History

Did the child have any concerns at birth? *

If yes, please provide details (including any treatments given)

Any additional pre-natal or birth information that might be relevant?

Developmental History

Please indicate the age at which your child did the following

Rolled over consistently *

Age

Sat up unsupported *

Age

Crawled *

Age

Walked unassisted *

Age

Said first word *

Age

Spoke in phrases *

Age

Used sentences *

Age

Toilet trained(Day) *

Age

Toilet trained(Night) *

Age

Self dressed *

Age

Please list any surgeries, serious illnesses, injuries, hospitalizations, allergies, ear infections or other special conditions your child has had in the past. Please indicate dates that these happened *

Does your child have any current medical concerns? *

If yes, please provide details

Please list any medication(s) your child is currently taking or had taken for extended periods (Medication, dosage and dates) *

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5

Does the child have any vision problem? *

Does the child have any hearing problems? *

Name of child's Pediatrician *

Address of child's Pediatrician *

ruoyPhone number of child's Pe diatrician *

Educational History

Please provide information on all schools attended (names, system years, days/hours attended, and indicate if its a special school) *

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Does your child's teacher have concerns about him/her? *

If yes, list concerns

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Has your child ever repeated a grade? *

If yes, which grade?

Does your child attend extended school during the summer months? *

If not, what does your child do during the summer months?

List any special abilities, skills and strengths your child has? *

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Behavioral History

If other please list them below

What are the things that make your child frustrated? *

State them here

What are the things your child have difficulty transitioning away from? (E.g being asked to do something else when playing video games) *

Rank your priorities for ABA interventions with 1 being the highest (if not a priority, leave blank)

Reduction of problematic behaviors

Rank

Increasing communications skills

Rank

Improvement in interaction with peers

Rank

Compliance with daily tasks/routine

Rank

Learning age appropriate hygiene skills

Rank

Learning age appropriate household activates

Rank

Please provide the following information: time home from school, other therapies with start/end times, recurring activities with start/end times, time child goes to bed

Monday

Start/End time

Tuesday

Start/End time

Wednesday

Start/End time

Thursday

Start/End time

Friday

Start/End time

Please upload a copy of your child's individual education plan (IEP) *

Please upload a copy of your child's diagnostic evaluation *

Please upload any other document pertinent to your child's education (E.g. Educational Assessment)